Does Medicare Cover Hep C Treatments?

Does Medicare Cover Hep C Treatments

Treatment for hepatitis C has come a long way in a short time. While there’s still no vaccine, a new class of drugs can now cure it for almost everyone.

These drugs made headlines when they first came to market—not for their efficacy, but for their eye-popping price tag. The cost? Over $1,000 per pill, or around $85,000 in all!

What is Hep C?

The Hep C virus spreads from contact with blood, most often from drug users who share needles. But that’s not the only way to get it. You can also get Hep C having sex or if you got a blood transfusion before 1992.

For a very few lucky people, a Hep C infection clears up on its own in the first six months. But a whopping 80% of infected people end up with chronic Hep C – where the infection sticks around and puts liver health at risk.

If you don’t treat it, Hep C can damage your liver, scar it (called cirrhosis), and cause liver cancer. That’s how more than 15,000 people died from Hep C in 2018 (those are the most recent stats).

How do I know if I have Hep C?

If you’re a Baby Boomer, you have a fairly high risk – but 40% of infected people don’t know they have it. Chronic Hep C usually has no symptoms until liver damage is dangerously bad. That’s why guidelines say all adults should get tested for the virus at least once.

Medicare covers the cost of testing once if:

  • you were born between 1945-1965 
  • you have a history of IV drug use (they’ll test you every year if you’re still using drugs with needles)
  • you received a blood transfusion before 1992 (so talk to your doctor about any operations you had before then; you might have gotten blood and not even known about it)

What’s different about the newer Hep C treatments?

You might have heard about the awful Hep C treatments, known as PR therapy, that used drugs like Interferon. With those, you had to take the drugs for almost a year – and the nasty side effects were often enough to make you quit. If you stuck with it to finish the treatment, you only had a 50% chance of getting cured. Half the people who put up with the whole treatment didn’t get better.  

That’s what was so amazing about the newer medications, like Harvoni and Epclusa, which are direct acting antivirals (DAAs). You take these drugs for a few months (usually 8 to 12 weeks) and they have minimal side effects with a success rate of over 90%. Clearly, they’re the better choice. 

Does Medicare cover the newer Hep C treatments?

The short answer is yes. Medicare requires each Part D or Medicare Advantage plan to have at least one of the new DAAs in its formulary, or list of covered drugs.

But the real answer is more complicated. Before we share the good news, here’s what you need to know: Even though one of these Hep C drugs is covered, your doctor can’t just write you a prescription. You’ll have to go through a few steps first:

  • Medical necessity: You’ll need to get coverage approved first (pre-authorization) before Hep C medications are covered – and you won’t get it unless the drugs are “medically necessary.” You might need to show that you have liver damage or you might need to try a less expensive treatment first. Work with your doctor on the testing and paperwork. It’s time consuming, but worth it. 
  • Patient readiness: You might need to show your “readiness” to undergo treatment. That could mean taking a urine test to show you’re not currently using recreational drugs. Your doctor may also need to promise that you’ll take the medications properly.
  • Cost: Because they’re expensive, even when they’re covered, these drugs can have a co-pay as high as 30%. You could be paying almost a third until you hit your policy’s out-of-pocket maximum – and you’ll probably still pay 5% of the cost after that. Even with insurance, that can add up. But don’t lose heart. Keep reading to find out how to make it work. 

Help for Hep C patients

So what’s the good news? There are places you can get help if your doctor wants to prescribe one of the DAA drugs. The drug companies have programs to give money to patients to help pay for treatment. Also, the government has an Extra Help program for Medicare Part D fees. And some nonprofit organizations, like the PAN Foundation, can help with costs.

For help getting coverage approved, ask your doctor to help you find a “specialty pharmacy.” These specialists know how to guide you through each step. And if Medicare turns you down for coverage, you can appeal the decision. Work with your doctor to look at the reasons you were turned down so you can fix them and try again.

Healthy habits for people with Hep C

While you go through the steps, here are some smart health habits that can help protect your liver if you have Hep C:

  • Eat healthy. Get plenty of fruits, vegetables, and whole grains. Try to cut back on trans fats such as margarine and saturated fats such as red meats and butter.
  • Exercise. Ask your doctor to suggest workouts that are safe for you, like walking. Getting a friend to walk with you is a great way to keep at it.
  • Don’t drink or use drugs. That doesn’t include medications your doctor says you should take, of course. Stay away from recreational drugs and alcohol. They’re hard on your liver. 
  • Check with your doctor before taking any medications, supplements, or herbs. Even over-the-counter medications, like acetaminophen in Tylenol, could be a risk for someone with Hep C.

If you’ve never been tested for Hep C, talk to your doctor about it. Now that there are treatments that cure most people, it’s smart to take action.

Additional sources:

Gloria Alcius
Gloria Alcius has been a Licensed Health Insurance Advisor since 2011. She enjoys building relationships with her clients and helping them better understand their Medicare options. Gloria’s goal is giving each customer peace of mind, knowing they have the right health insurance for their unique needs. In her spare time, Gloria enjoys spending time with her family, cooking, and traveling.


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