Most common reason for denial was “insufficient information to assess medical need”
WEDNESDAY, Nov. 25, 2015 (HealthDay News) — Nearly half of Medicaid patients with chronic hepatitis C have been denied newer direct-acting antiviral medications, due to tight controls that states have placed on coverage of the drugs. These findings were presented at the annual meeting of the American Association for the Study of Liver Diseases, held from Nov. 13 to 17 in San Francisco.
Vincent Lo Re III, M.D., an assistant professor of medicine and epidemiology in the division of infectious diseases at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues analyzed prescriptions submitted to pharmacies that serve patients in Pennsylvania, New Jersey, Delaware, and Maryland.
Out of 2,342 patients who submitted a prescription for one of these new drugs between November 2014 and April 2015, a total of 377 (16 percent) received an absolute denial, the researchers reported. Of the 377 denials, 233 were handed down to Medicaid patients, compared with 104 for privately insured patients and 40 for Medicare patients. The most common reasons for denial by Medicaid were “insufficient information to assess medical need” (48 percent), “lack of medical necessity” (31 percent), and a positive alcohol/drug screen (4 percent).
“For Medicaid patients, 46 percent were denied direct-acting antiviral therapy, and they had a longer time to fill than those with other insurance,” the authors conclude. “Medicaid programs should seek to increase access to direct-acting antiviral agents for chronic hepatitis C virus-infected patients.”
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