Florida changes Hep C drug policy for Medicaid after lawsuit

FORT LAUDERDALE, Fla. (AP) – Florida health officials are changing the state’s policy for administering costly hepatitis C drugs to Medicaid patients and will now require insurance companies to provide the drug at an earlier stage in the disease.

The change comes after three organizations sued in April, warning that the Florida Agency for Health Care Administration’s policies violate patient rights under the Medicaid Act. Previously, hepatitis C patients were only given the medication when they were at a so-called fibrosis level three or four. Patients often have such severe liver damage in stage four that they require a transplant, said Vicki Tucci Krusel, an attorney with Legal Aid Society of Palm Beach County.

“But everyone who’s F zero, one and two was not getting the medication, so the state was basically waiting until someone gets really sick instead of getting someone the medication they need to get better now. Under the amended criteria, the fibrosis level is no longer a requirement,” said Krusel, who filed the suit along with Florida Legal Services and the National Health Law Program. “The policy change will ensure the health of Medicaid recipients statewide. I hope other states follow Florida’s lead.”

The change went into effect Wednesday. Florida health officials said they would give the insurance companies that administer Medicaid program until June 17 to make the changes and noted plans could still review cases to prove that patients aren’t using drugs or are seeking substance abuse treatment.

The drugs which can cost between $24,000 and $31,000 a month. It’s unclear how many Medicaid patients in Florida have hepatitis C or have been denied the drug.

Vickie Goldstein, a 57-year-old Palm Beach County resident, said her health plan denied her Antiretroviral drug used to treat hepatitis C last summer saying it was not medically necessary. The three legal organizations sent a letter on Goldstein’s behalf asking the state to amend its criteria for dispensing hepatitis C treatment and medications to fall in line with federal Medicaid guidelines. The lawsuit is likely to be dismissed after the changes.

“Despite the fact that there is a cure for this infectious disease, too many people have died because they had no access to the treatment,” Goldstein said in a statement. “Now, this will start to change in Florida because we have shined a spotlight on the barriers to access treatment for this disease.”

The issue has been common as states with limited Medicaid budgets have struggled to pay for these new expensive, yet often life-saving medications that have emerged in the last few years. An investigation by the U.S. Senate Finance Committee found Medicaid programs were only able treat 2.4 percent of roughly 700,000 enrollees infected with the disease, despite spending more than $1 billion on the drug during 2014.

On Friday, a federal judge ordered Washington Medicaid to provide the drug to all hepatitis C patients, not just the sickest ones. The injunction was a response to a class-action lawsuit filed in February on behalf of two of the state’s Medicaid clients, seeking to force the state to stop a 2015 policy that restricted access to the drugs based on a measure of liver scarring.

Patients typically need two to six months of treatment, which can cost as much as $180,000. Depending on the patient’s treatment history and the drug being used, the medications are 96 to 100 percent effective, said Chris Dowden, a pharmacist at Skyemed Pharmacy based in West Palm Beach.

Typically, patients try to get the medication and are denied by their insurance company. They appeal and are denied again, but the state usually approves the drug during an appeals hearing – a process can take several months, Dowden said.