Medicaid Plans to Get Extra Drug $

Jun 10, 2014

Florida Medicaid officials have decided to give an extra payment to managed-care plans to cover the unexpected cost of a new treatment for a common viral illness, Hepatitis C.

Credit Courtesy of Gilead Sciences Inc.

The Agency for Health Care Administration intends to make a "kick payment" to plans to help them cover the drug Sovaldi, Press Secretary Shelisha Coleman said. That's the term used when an agency gives additional payments beyond the contracted amount because of unforeseen circumstances.

Coleman said details on the payments, including the amount, should be ready by June 30. AHCA officials say they don't think they will have to submit a supplementary request to the Legislative Budget Commission.

The kick-payment news will be a relief to the HMOs and PSN's (provider-service networks, which are mostly non-profit plans operated by hospitals, physician groups or clinics) staggering under the price of Sovaldi. Gilead, the manufacturer, is charging $84,000 for one 12-week course of treatment; the drugs that must be given with it brings the cost to about $90,000.

"When we got our rates they did not contemplate the inclusion of Sovaldi because it hadn't yet been approved," Dr. Mario Molina, CEO of Molina Health Plans, told Health News Florida last week. 

He said that if all Floridians who have hepatitis C infection were to be treated with the drug, it would cost billions of dollars. He estimated that 60 percent of those who are infected nationwide are enrolled in Medicaid.

Coleman said about 20,600 Florida Medicaid patients were diagnosed with Hepatitis C last year.  Most are not so seriously ill that they would meet the criteria AHCA set up for treatment with one of the new treatments, Sovaldi and Olysio. 

"Only about 16 percent of people who are infected with Hepatitis C will go on to develop full-blown cirrhosis," Molina said.  But the problem, he said, is "we don't have a good way of predicting who needs to be treated."

Virtually all Medicaid patients who are diagnosed with Hepatitis C will be enrolled in managed-care plans by August, since Florida now requires them to. The plans have already signed contracts with AHCA that tell them how much money they have available, although there are some built-in protections to help with catastrophic cases.

AHCA, with help from an advisory committee of physicians and pharmacists, has set up criteria that plans should use for approval of Sovaldi and Olysio to limit the drugs' use to severe cases.

The medical criteria include: stage 3 or 4 disease (with 4 being the highest); a particular genotype for the virus, since not all respond to the medication; and a minimum viral load.

In addition, the patient must be free of drugs and alcohol for at least a month, as demonstrated by urine or blood tests, or must be receiving counseling for substance or alcohol abuse at the time of the hepatitis treatment.  

Hepatitis C is transmitted by body fluids. Some of those who are infected were drug abusers who shared needles, although some got the virus from blood transfusions decades ago or were infected at birth.

Presumably the requirement for drug-free behavior was inspired by a concern -- expressed by advisory committee members -- that patients might be given the expensive drugs and be cured of disease, only to resume drug use and get it again.

Use of alcohol is presumably listed because it causes further damage to a liver that is already ravaged by the virus.