Will Medicaid pay for hepatitis C treatment?

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Doctors use various antiviral medications to treat hepatitis C. These drugs attack the virus and can usually cure the disease. Older drugs include:

• ribavirin
• peginterferon alfa-2a (Pegasys)
• peginterferon alfa-2b (PEG-Intron)

Since 2013, newer drugs called DAAs have received approval to treat the condition. Even if an individual has chronic hepatitis C, these drugs can usually cure the disease.

A doctor may prescribe the following newer antiviral medications to treat hepatitis C:

• daclatasvir (Daklinza)
• elbasvir or grazoprevir (Zepatier)
• glecaprevir-pibrentasvir (Mavyret)
• ledipasvir-sofosbuvir (Harvoni)
• sofosbuvir (Sovaldi)

Although hepatitis C is now treatable, treatments can be expensive. For example, one pill of Sovaldi costs around $1,000, and the total cost of the 12-week treatment is $84,000. Zepatier is another example of a costly drug, with cost estimates at around $54,600 for a 12-week treatment course.

Because hepatitis C treatments have high costs, insurers and Medicaid may deny coverage or have restrictions.

Learn more about the costs of hepatitis C treatment.

Medicaid is a government-funded assistance program that provides healthcare coverage to low income individuals and families. Often, people receive free medical care, although they may need to pay a small copayment.

Coverage varies by state because local governments run the programs within federal guidelines.

There are currently over 86 million people enrolled in their state’s Medicaid and Children Health Insurance Programs.

The exact eligibility criteria for Medicaid may vary by state. Generally, the program provides free or low cost healthcare to low income people, families, children, pregnant individuals, and those living with disabilities. However, some states have expanded the programs to cover anyone with income below a certain level.

The government uses a person’s modified adjusted gross income to calculate their eligibility. This figure consists of their taxable income and deductions such as Social Security benefits, retirement contributions, and tax-exempt interest.

If a person makes less than 138% of the federal poverty level (FPL), they may qualify for a Medicaid program. In 2022, the FPL for individuals is $13,590.

Additionally, there are nonfinancial eligibility criteria, including the following:

• they are a resident of the state in which they are applying
• they are a citizen of the United States or a lawful permanent resident
• their financial situation is low income

Many states have potentially discriminatory restrictions in place that prevent Medicaid enrollees from accessing hepatitis C medications.

Some research has indicated that Medicaid restricts individuals’ access to certain hepatitis C drugs beyond the recommendations of professional organizations.

Restrictions in place in some states include:

• barring people with a history of alcohol or substance use
• requiring that individuals reach a certain stage of liver disease before treatment
• allowing only certain specialists to prescribe treatment

If individuals have difficulties with alcohol use disorder, Medicaid may restrict or deny hepatitis C treatment. For example, in Alabama, an individual must abstain from these substances for 6 months before starting hepatitis C treatment, as of April 2022. Delays in these types of treatments can have serious consequences for a person’s health, as they can lead to liver damage or even death.

Likewise, in Nebraska, Texas, Arkansas, and South Dakota, people must wait until hepatitis C damages their liver before receiving treatment.

Restrictions also include the type of physicians that can prescribe treatment. In the United States, more than a third of states have these limits in place so that only hepatologists, gastroenterologists, or infectious disease specialists can prescribe hepatitis C treatment. Therefore, individuals who live in rural or other areas with no availability of specialists cannot gain access to the life-saving medications they need.

However, hepatitis C treatment restrictions have eased over the last decade since the introduction of new, effective drugs. Now, increasing numbers of people living with hepatitis C can access medications through Medicaid.

If an individual cannot rely on Medicaid to cover their expenses for hepatitis C treatment, there are other potential sources of funding, including:

• The American Liver Foundation (ALF): ALF provides a financial assistance resource support guide where people may find helpful information. It also offers a free drug discount card that may lower the cost of some prescription medications.
• NeedyMeds: An organization that provides details of assistance programs for medication costs. People can also access a database of free and low cost medical clinics.
• Help-4-Hep: This helpline from a hepatitis nonprofit organization provides counselors who can help people locate financial resources. The number is 877-HELP-4-HEP (877-435-7443).
• The HealthWell Foundation: This foundation may provide financial assistance for individuals living with hepatitis C.
• The Patient Advocate Foundation: This organization helps people cover co-pays and provides resources that may help with medical expenses.
• Pharmaceutical programs: Some pharmaceutical companies offer free of charge or lower cost medications to low income individuals without insurance or who do not receive government support. A person can ask their doctor to contact these companies directly.

Hepatitis C can be a severe disease, but various antiviral drugs can cure the condition. However, these treatments are expensive, and Medicaid may not cover the costs for everyone. There may be restrictions in place that prevent Medicaid enrollees from accessing hepatitis C medications.

Some states restrict treatment to individuals with liver scarring, those who abstain from certain substances for several months, or by the prescriber.

Although Medicaid might not be able to help with treatment costs for some people, individuals can turn to various resources to help them fund life-saving hepatitis C medications.