Plans are investing resources to ensure appropriate
use and increase the likelihood of achieving a
sustained viral response. On average, commercial
plans are significantly more likely to use three or
more interventions to manage use and access for
hepatitis C agents than for other specialty categories
(see Figure 2). Notably, the percentage of plans using
this level of intervention rose nearly 20 percentage
points, from 57% to 75%, in the last year. If this trend
continues, we can expect virtually all plans to be
using multiple management tactics and interventions
for hepatitis C products in the near future.
Despite limited resources, many managed Medicaid
plans have also steadily increased management
of hepatitis C agents over the past few years.
Specifically, the number of Medicaid plans utilizing
five or more interventions to manage hepatitis C
agents has nearly doubled every year since 2012 (see
Figure 3).
Plan Interventions Mitigate
Inappropriate Use and Influence
Treatment Selection
High drug costs, potential for inappropriate or
unsafe use, and defined protocols for achieving
optimal success compel plans to rely heavily on prior
authorization requirements to judiciously manage
drug utilization (see Figure 4). PA criteria align closely
with FDA-approved product labels and industry
clinical guidelines. In addition, most plans limit initial
authorization of current agents to 12 or fewer weeks
to align prescribing with complex label specifications
relating to patient type and clinical response.
Stricter oversight allows plans to mitigate costs due
to early discontinuation of ineffective or intolerable
therapies. Seeking to document and ensure accuracy
of patient response, most plans evaluate actual
medical records prior to approving continued use
of hepatitis C agents. Plans’ investment of critical
resources to conduct medical records evaluations
emphasizes their high level of interest in mitigating
costs through utilization management.
Figure 2
Commercial Health Plan Management Intensity for Hepatitis C Products2
(Percentage MCOs using number of interventions)
n = 51, 2013; n = 36, 2014
Figure 3
Managed Medicaid Plans Using Five or More Interventions
for Hepatitis C Products3
(Percentage Medicaid MCOs)
n=30, 2012; n=40, 2013, n=28, 2014
Figure 4
Plan Use of Prior Authorization Ensures Appropriate Use
and Optimal Outcomes1
(Percentage enrollment)
n=41 with 150.5 million total lives
34