Gilead’s My Support Path was helping a lot of people. Why did it stop?
Since payers (mostly insurance companies) would only approve the drug under restricted access it minimized what payers were actually paying. When a payers’ client signs up through my support path the idea is that the insurance is supposed to pay what they intended to, and Gilead would reduce the remaining price to a place where patients could better afford it according to what they could afford.
But some payers would instead restrict access mimicking Medicaid’s practically criminal restrictions on the drug. Which means that despite tens of thousands of people having insurance, their insurance would deny them coverage. Patients acted in good faith and signed up for My Support Path before denial occurred and Gilead would often end up footing the entire bill besides the reduced co-pay which could be as low as five dollars per bottle.
So Some payers is a PR positive mischaracterization. I use it because Gilead used it to describe the situation.
There are hundreds of payers, but there are large payers who have some of the more extreme restrictions which typically set the standard pace.
This is the Sovaldi disqualifying event list for Kaiser.
Kaiser is not the only big payer, but it’s one of them. It’s also fighting an odd PR war with Gilead.
Anthem-Blue Cross/Blue Shield(second largest in the US by market share) has similar restrictions.
If you have Kaiser and want Sovaldi there are about 29 criteria, one of which is a partner medication, which increases the criteria anywhere between 3 and 8 more. This is just the list for Sovaldi (Sofosbuvir) and Olysio (Simeprevir), It’s representative of at least Portland’s North West Kaiser policies. I chose Portland because of Oregon’s high HCV death rate, their high growth rate and their restrictive Medicaid policies for HCV.
So would I, An HCV patient with Genotype 1a Q80k Polymorphism and a decompensated F4, stage 4 liver, be prescribed Sovaldi if i were to use Kaiser?
No. This would be my Disqualifying question: “ Has the patient failed treatment with a protease inhibitor, such as boceprevir or telaprevir? If yes, do not approve. DENIAL TEXT: Approval with Simeprevir requires no prior treatment with a hepatitis C protease inhibitor. ”
Incivek (Telaprevir) was a protease inhibitor, while Sovaldi is a polymerase inhibitor. They target completely different nonstructural proteins, It’s like comparing apples and pears. So the fault here lies in Sovaldi’s need to be a partner medication. While Olysio on it’s own is a protease inhibitor and is not recommended the Sovaldi/Olysio combo only has about a 74% success rate with my circumstance, and a 96% success otherwise.
(BTW if you disqualify because of this,you can appeal it. The COSMOS study can help win your case, you’ll need to talk to your doc about your plan’s specifics.) It’s part of what i did to get Sovaldi.
One of the questions that bothers me the most is this one: 7. Does the patient have severe non-liver related comorbidity causing diminished life expectancy to < 5 years? If yes, do not approve.
What this question is asking is does the patient have two diseases (one of which being HCV) that when in combination decrease life expectancy to less than five years.
It does not seek to ascertain if that life expectancy were to increase due to treatment of HCV. In other words, if you have less than five years left, and if you’re cured and you could have 15 or 20 years left to live...you’d be denied.
I wish i could say Kaiser were alone in this. But Kaiser is an industry leader for Healthcare (and the third largest in the US.)
For a good comparative understanding of HCV drugs that are and are not covered this is consolidated Covered California Formulary. Insurers are trying to avoid paying for the new HCV meds Like Sovaldi, Olysio, Harvoni, Viekira Pak which their clients need.
While Gilead’s My Support Path used to be able to potentially help hundreds of thousands of people.
Gilead isn’t a victim per-say, it’s a target. Gilead made the error in releasing two HCV meds within a year. Unaware that they’d create a historic late quarter surge which occurred due to combined profits from Sovaldi now playing second fiddle to Harvoni (Sofosbuvir/ledipasvir). How do other drugs fair?
While Interferon, Peg-Interfereon, Ribavirin are all relatively cheap now, they didn’t used to be.
Let’s keep in mind that the last HCV cure Peg-Interferon, Ribavirin and Incivek(teleprivir) treatment wasn’t cheap either.
"The median cost of treatment was $83,509 -- about 65% of that for telaprevir -- but only 44% of patients achieved an SVR, so that the per-cure cost was a whopping $188,859."
Peg-Interferon and Ribavirin had a worse SVR when they came out than they do today. (a lot of that has to do with targeting genotypes) and it buckled for around a grand a week.
With 48 weeks being the standard treatment.
By comparison Gilead’s Cure rate for Sovaldi/Harvoni is 90%+ and cost $84,000.
With a 24 week treatment, and as low as 12 weeks for most people it’s life changing.
Gilead doesn’t just produce HCV Meds, check out their timeline to better understand how big of a company they are.
Pharmaceutical drugs as a whole have a devastatingly lucrative patent system in the United States. And if you think Gilead is a good target for its prices, it’s just par for the course.
Insurers aren’t the white knight either, keep in mind that those denial clauses stem from years of there being potentially better drugs on the horizon, and at the time very potentially dangerous treatments.
Insurers need to update their line of thinking with today’s climate of HCV meds. To assist Governments and Insurers the EASL updated recommendations in 2015 and a lot has changed in this past year.
Here in the United States the AASLD has released a similar recommendations list.
These recommendations are contrary to many of the denial clauses insurers presently use. The idea behind the recommendations is to encourage the best treatments be as affordable and accessible as possible.
I’ve been on each of the major treatments. Incivek nearly killed me, and I was willing to go through 48 weeks of it for a few hundred dollars less than Sovaldi.