The Centers for Medicare and Medicaid Services (CMS) has issued important new guidance to states, addressing restrictions that state Medicaid programs and Medicaid Managed Care Organizations (MCOs) have instituted to limit access to newer treatments for the hepatitis C virus (HCV). These restrictions were outlined in a June 2015 journal article, “Restrictions for Medicaid Reimbursement of Sofosbuvir for the Treatment of Hepatitis C Virus Infection in the United States,” published in the Annals of Internal Medicine.
The CMS notice issued a reminder to states noting the following:
- They are required to cover medications to treat HCV under the terms of the Medicaid Act;
- Budgetary impact is not a sufficient justification to exclude HCV medications;
- Limitations on access (such as limitations of treatment to individuals with a fibrosis score of F3 or F4, requiring sobriety periods, and limiting the ability of providers to prescribe to a narrow range of provider types) are unreasonable and states should follow the HCV Treatment Guidelines to guide their coverage policies;
- Medicaid MCOs must match fee-for-service plans in access to treatments; and
- CMS will monitor state compliance.
The Hepatitis Education Project has drafted a template letter/white paper to be used to reach out to state insurance commissioners in light of this new guidance from CMS.