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Medicare Reverses Denial of Costly Treatment for Hepatitis C Patient

May 19, 2014

This article was reported by The Reporter.

The Reporter announced that Medicare has reversed its decision and will cover the cost of the expensive new drugs to treat an Arizona man with hepatitis C virus (HCV) infection. Medicare officials have stated that the new policy will be used for HCV patients whose doctors prescribe combined use of the two drugs if the patients meet the criteria presented in January by the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases. The guidelines recommend combined use of the two drugs for patients with advanced liver disease who were not cured by earlier drug treatments.

Medicare officials contend its beneficiaries should receive required treatment if they demonstrate "medical necessity" and have "medically accepted indications" for the treatment. Medicare is consulting with medical specialty groups to make improvements to the guidelines concerning when patients should receive treatment and with what treatments. At present, Medicare's Part D plans to make a case-by-case decision on whether to approve payment for the expensive treatment. The agency expects to be able to determine the potential costs of covering the drugs after it receives bids that include the cost of the new treatments from Part D drug plans.

Sovaldi, one of the new drugs, costs $84,000 for a typical 12-week treatment, but some patients may need treatment for 24 weeks. The other drug, Olysio, costs approximately $66,000, but is approved for a smaller group of patients. These drugs are used in combination with others, which increases costs even more.

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