Medicaid Relaxes Prior Authorization for Hep C Antiviral Drugs
By Joey Berlin Texas Medicine September 2021

Antiviral Medication

For years, Texas Medicaid patients with hepatitis C haven’t had access to overwhelmingly effective, often-curative antiviral therapy unless they had advanced liver disease. In many cases, getting the antiviral drugs at that point was too little, too late.

“That’s like having a person in the desert that doesn’t have access to water, then you’ve got a bathtub filled with water, and you won’t let them drink even a sip,” said New Braunfels family physician Emily Briggs, MD. “It just doesn’t make any sense. It is a life-altering treatment modality.” 

The Texas Medical Association and others have advocated for change for years. And this year, the Texas Legislature made it happen. 

The state’s budget for 2022-23, ironed out during this year’s regular legislative session, included $51 million in state and federal funds to increase the availability of direct antiviral agents (DAAs) to treat Medicaid patients with hepatitis C. Although it was less than half of the Texas Health and Human Services Commission’s (HHSC’s) original $115 million funding request, it was enough to significantly change the game for hepatitis C patients whose condition hasn’t progressed to advanced liver fibrosis. 

As a result, HHSC in late June announced a policy change significantly curbing prior authorization barriers that prevented patients with hepatitis C from timely access to DAAs. The changes are effective Sept. 1. The budget also specifies that if the DAAs’ costs exceed the funding allocated to HHSC, the agency can shift funds to cover the additional costs. 

More than half a million Texans are believed to have chronic hepatitis C, according to HHSC’s 2020 State Plan for treating the disease. 

David Lakey, MD, vice chancellor for health affairs at The University of Texas System and former commissioner for the Texas Department of State Health Services, says the state of hepatitis C care changed rapidly in the recent past, as science developed direct antivirals with overwhelming effectiveness at treating the disease. 

“They’re much easier to tolerate than [what we had] a decade ago, when you had Interferon-based treatments that weren’t really well-tolerated and didn’t have this type of effectiveness,” Dr. Lakey said. 

He says many physicians believe that now the health care system should rethink how it approaches the disease: “Going from where we were before – which was finding the people that were most likely in the near future to develop cirrhosis, and getting those individuals treatment – to ... getting anyone that’s infected with it on treatment and getting them cured of hepatitis C.” 

One barrier between those patients and antivirals was financial because of the high cost of the drugs. But the infusion of funding – a several-years-long cause for TMA and others in organized medicine – largely addressed that. 

HHSC Chief Medicaid Director Ryan Van Ramshorst, MD, announced several key changes: 

  • Treatment with a DAA medication that’s on the drug formulary will be available to Medicaid patients “regardless of Metavir fibrosis score,” which measures the severity of fibrosis seen on a liver biopsy. 
  • Specialists such as gastroenterologists are no longer the only physicians who can prescribe DAAs. “General practitioners,” including primary care physicians, can also prescribe the medicines, HHSC said. 
  • Drug screenings are no longer required.  

The increased availability of direct antivirals in Medicaid is “huge,” Dr. Briggs said. 

“We have [had] an unfortunate dichotomy of patients … that could afford [treatment] and patients that couldn’t afford this treatment,” she said, adding that patients can see their lives lengthened significantly. “They’re not dealing with the uncertainty of a chronic disease versus having it eventually be cured – having something where they’re no longer having to be concerned about what their liver is going to do in the long run, becoming cirrhotic or receiving a transplant or something like that, especially from a viral infection.” 

However, as Dr. Lakey notes, many other patients not in the Medicaid population still need screening and treatment for hepatitis C. And Dr. Briggs adds there are other, nonfinancial barriers still existing between patients and the DAAs that could save their lives. 

HHSC addressed one of them in part with its policy removing required drug screenings; Dr. Briggs says right now, patients “have to prove that they are worthy, essentially, of getting treatment” by proving they aren’t drinking alcohol or taking illicit substances. 

The medical thinking, she says, was that a patient must be free of any other liver-affecting issues before receiving hepatitis C treatment. But whether patients have a substance use problem or not, they still need treatment, Dr. Briggs adds. 

“Hepatitis C is not something that is alcohol-related. Yes, alcohol and hepatitis C both affect the liver, so you can imagine that both of those together would be a problem. But only providing treatment to a person that has no other risk factors for liver issues just doesn’t fly,” she said. “We need to make sure that everybody that has hepatitis C is offered that opportunity to have essentially a cure for it.” 

The progress made in Medicaid, she said, was due in large part to TMA listening to its membership. 

“Clear advocacy of our efforts, but also of the staff helping us to be as well-informed, as well as meeting with the right legislators to get that message out there,” she said. “TMA was instrumental in getting this change to happen.”  

Tex Med. 2021;117(9):46-47
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Last Updated On

September 06, 2021

Originally Published On

August 31, 2021

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