Procession of the Foibles

By: Marcus J. Hopkins, Blogger

In last week’s HEAL Blog, we discussed in detail the prerequisites required to qualify a patient for coverage under the State of Illinois Department of Healthcare and Family Services’ new HCV drug Prior Authorization (PA) process. This was a basic checklist that includes questions about how far along (i.e. – how “sick”) a patient is, as well as whether or not they’ve modified any deleterious behaviors for long enough to even be considered for treatment. This week, we are focusing not so much on the criteria required to begin the process, but on the process, itself.

Cartoon image of an explosion with the words, KA-POW!

Photo Source: Armchair Chef

I’ll begin this post with an anecdote:

This past summer, I was privileged to attend the National Viral Hepatitis Roundtable (NVHR) session, hosted by the National Alliance of State and Territorial AIDS Directors (NASTAD). During one of the afternoon segments, we were addressed (via telephone) by two officials from the Centers for Medicare and Medicaid Services (CMS), and the conversation quickly became tense.

During this conversation, several of the participants voiced their concerns and frustrations regarding the PA process for the newer HCV drugs. This included a representative from Walgreen’s pharmacy. When this particular person mentioned how cumbersome the process had become, one of the gentlemen from CMS responded, “You work for Walgreen’s? I’m not certain why you’re complaining. Isn’t filing PAs part of your job?”

What was striking about this exchange to virtually everyone in the room was the level of incredulity and annoyance this response implied – a sense that CMS has heard enough of this type of grousing, so he should just shut up and get on with doing his job. In researching the PA process with other Medicaid representatives, I encountered a similar level of exasperation from numerous employees – that they already know the process is beleaguered, and they’re tired of hearing about it.

The implications of this type of reaction are seemingly stark – the process is what it is, and no one is likely to come along and change it, so you might as well suck it up, and do the paperwork. This is the way bureaucracy works, and it’s just the price everyone has to pay if they someone else to pay the piper.

Anecdotal experiences aside, the reality is that there isn’t just one way to establish a PA process; each payer (private or public) has its own way of doing things, which means that each provider (physician or pharmacist) may have to do each step of the process differently, depending on who’s going to be paying. There is little standardization, when it comes to HCV drug PAs.

The PA process is essentially broken down into several steps filled out and filed by each provider along the way. It usually begins with the prescribing physician, who starts the ball rolling by ensuring that each patient individually meets the prerequisites to even begin the PA process. Once that is established, they begin to fill out paperwork, such as this version from Illinois’ Medicaid program. This is form provides the payer with basic information about the prescribing physician and the patient, and requires the submission of documentation showing the following – METAVIR or equivalent fibrosis score, long-term and recent test results showing that the patient has tested negative for drug screenings for the last year and fifteen days prior to beginning the regimen, and whether or not the patient is committed to treatment (which I assume means that the doctor must vouch for the patient in writing). After the physician submits the initial PA request, the payer will determine whether or not they will agree to pay for the treatment.

But, the paperwork doesn’t stop, there; the process continues with the next provider patients see – their pharmacist. In order to ensure that they are allowed to fill the prescription for each HCV-infected patient, they must be provided with the approved PA form from the physician, and then, submit their own form that again requests a guaranteed payment before the drugs are dispensed.

If a PA request is denied during any step along the way, each person must file an appeal to the decision, and potentially a second appeal, all in an effort to provide their patients with the treatment their physicians have deemed necessary.

In states that require proof of “Medical Necessity” – meaning all other treatment regimens have failed the patient – the process can take even longer, as the patient will have to attempt each regimen, including those whose side effects so negative and tolerability are so low, failure is essentially guaranteed. This places a burden on both physicians and patients, as both parties have to confront and cope with the outcomes of each failed attempt to cure HCV.

So, the question becomes, “Is there any respite in sight?” Honestly, until prices for these drugs drop significantly, it’s very unlikely. The PA process is designed to ensure that payers aren’t doling out money for therapies that are going to go to waste, either from a patient’s refusal to comply with the regimen or if they require a second round of treatment. Regardless of how fabulously these drugs do their job in attaining a Sustained Virologic Response (SVR – “cure”), they are simply too expensive for payers to simply approve and pay for treatment for everyone who seeks coverage.

In next week’s HEAL Blog, we’ll explore some of the options that some patients may utilize in lieu of coverage from a 3rd party payer – Patient Assistance Programs (PAPs).


Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.


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