Updated on May 27, 2022.
You might have heard horror stories from people with hepatitis C about health insurance companies refusing to cover newer medications that have cure rates above 90 percent. Unfortunately, research confirms that getting coverage is often a battle.
Who is denied
A 2018 study published in Open Forum Infectious Diseases looked at 9,025 patients prescribed a hepatitis C treatment. Of those, 4,702 were covered by Medicaid, 1,821 by Medicare, and 2,502 had commercial insurance. A total of 3,200 patients (35.5 percent) were denied treatment. Denial was more common among patients covered by commercial insurance (52.4 percent) than Medicaid (34.5 percent) or Medicare (14.7 percent).
Here are a few reasons insurance companies can deny claims:
- High cost of these therapies
- Evidence of advanced liver fibrosis (scarring which may result from hepatitis C)
- Evidence of alcohol abuse
- Evidence of illicit drugs
New oral medications are expensive, and with an estimated 2.4 million people living with hep C in the United States, the overall bill is a large one that many insurance companies are hesitant to pay.
Most people who have initially been denied eventually get their meds, however, but only after a lengthy appeals process. The bad news is that hep C can continue to damage your liver during that waiting period.
Research shows that having hep C increases your risk for liver cancer and B-cell non-Hodgkin lymphoma, and delaying treatment increases those risks.
What you can do
If you are denied coverage, there are several things you can do to help get the treatments you need:
Write an appeal letter. If you're told “no” on your first try to get treatment, you can appeal the decision. Each insurance company is different, but most have several levels of appeals. Take the time to research your options and what the appeals process will look like for you. Some healthcare provider (HCP) offices may offer to handle this, so ask your HCP if they can help in any way.
See the right HCP. If your provider is not prioritizing your treatment how you'd like, it might be time to see someone else. Some insurers may only cover hep C prescriptions from specialists, so you may need a referral to have a better chance at getting treatment.
Seek help for substance use if you need it. If you are denied coverage for your medications due to drug or alcohol use, it may help to provide documentation of assistance you’re receiving for the issue. Reach out to your insurance provider to learn how participating in a substance abuse program may increase your chances of getting your treatment covered.
Try the drug manufacturer. Many pharmaceutical companies have patient assistance programs to help people pay for their pricey drugs. They're a great resource, especially if you're uninsured. Check out the website of your preferred medication for more info on how you can qualify for financial assistance.
Be your own advocate. You are the person who cares most about your health, so take charge. Be a champion of your health by talking to your HCP about your treatment options. During this potentially exhausting time, it’s also important to be mindful of your mental and emotional health. If you have the resources, it can help to join a support group or reach out to speak with a counselor or therapist.
While trying to get your medication, you should remind yourself that being free of hep C is worth the wait and frustration. Fight for your treatment so you can rid yourself of hep C for good.
