Texas Medicaid holds off on proposed limits for Gilead hepatitis drug

April 11 Fri Apr 11, 2014 12:22pm EDT

April 11 (Reuters) - Texas is reconsidering whether to impose strict limits on Gilead Sciences' $84,000 hepatitis C treatment for patients on the state's Medicaid health plan for the poor, at the urging of outside advisers, a state official said on Friday.

The Texas Health and Human Services Commission, which oversees Medicaid, had proposed a policy to allow the drug, Sovaldi, to be used mainly for sicker patients, such as those whose hepatitis C had developed into advanced liver disease, according to state documents reviewed by Reuters.

As with most state Medicaid programs, an outside committee of pharmacists and doctors in Texas meets quarterly to review new drugs and recommend policies to the state's Medicaid director. The agency had been planning to begin offering coverage of the drug in July if the committee recommended the policy at its Thursday meeting.

"The board asked state staff to meet with stakeholders, including gastroenterologists, about the criteria, whether it was too strict, and the prior authorization process," Texas Health and Human Services Commission spokeswoman Stephanie Goodman said. In the interim, Medicaid patients in Texas will still not be prescribed the drug.

"We're looking at our options and how that will affect our timeline to get the drug covered," Goodman said.

The deliberations in Texas, one of the most populous states and home to a relatively large number of hepatitis C patients, underline the difficulties of state health officials in deciding how to cover the Gilead treatment. It was expected to be the first major state to make a decision; discussions are continuing in California, Colorado and Virginia among others.

Sovaldi has become the focal point for a global outcry over the price of novel medicines, attracting criticism from the World Health Organization, doctors' groups, state officials and insurance industries. The drug is the first to provide a true cure to the disease for most patients who take it, but its cost could reach more than $200 billion if widely used in the United States, posing huge risks to state budgets and insurers' financial results.

The Texas move has also tabled a plan that the state had hoped could also be in place by July to make supplemental payments to insurers to help offset the high cost of the drug.

Gilead Sciences received U.S. regulatory approval for the treatment in December. Many patients are prescribed the drug in combination with another new drug, Johnson & Johnson's Olysio, pushing the cost of a 12-week treatment to around $150,000.

Texas is among states including California and Florida which were asked by insurers who manage Medicaid plans to pay for the treatments directly, a move they said was needed because they would otherwise lose money on their contracts.

California is still discussing the issue. Florida said it has no plans to carve out the drug but continues to monitor the drug's use within managed care plans. (Reporting by Caroline Humer; Editing by Michele Gershberg and Jonathan Oatis)

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