Medicaid provides coverage for hepatitis C treatments?
In a significant policy shift, all 50 states and the District of Columbia now provide expanded Medicaid coverage for hepatitis C (HCV) treatment, marking a significant step towards improving access to curative therapies among low-income individuals.
Previously, access to HCV treatment via Medicaid varied greatly depending on the state a person lived in. Some states limited treatment to those with liver damage, while others imposed sobriety requirements or required prior authorization. However, as of July 2025, fibrosis (liver scarring) or sobriety restrictions have been eliminated everywhere, and prior authorization remains a potential hurdle in some states.
The elimination of these restrictions means that patients no longer need to meet liver damage severity criteria or abstain from drugs or alcohol before treatment. This expansion of coverage has been reflected in updated clinical guidelines, which now include children aged 3 and older in eligibility for direct-acting antiviral therapy.
While generic Epclusa (sofosbuvir/velpatasvir) coverage is nearly universal, some states have adjusted their Medicaid formularies. For instance, Nevada removed several key HCV drugs from the preferred list, while South Carolina added drugs like Epclusa.
Despite this widespread expansion, the high cost of HCV treatments remains a challenge. A 12-week course of Zepatier, another costly drug, can cost around $54,600. However, efforts are being made to facilitate access and equity in HCV treatment. For example, some pharmaceutical companies offer free or lower-cost medications to low-income individuals without insurance or government support.
In addition, various organisations offer resources to help individuals navigate the complexities of accessing HCV treatment. Help-4-Hep is a helpline that provides counselors who can help people locate financial resources for HCV treatment. The American Liver Foundation provides a financial assistance resource support guide and a free drug discount card. NeedyMeds offers details of assistance programs for medication costs and a database of free and low-cost medical clinics. The Patient Advocate Foundation helps people cover co-pays and provides resources that may help with medical expenses.
It's important to note that Medicaid eligibility criteria include being a resident of the state, a US citizen or lawful permanent resident, and having a low income. The federal poverty level (FPL) for individuals in 2022 is $13,590.
In summary, there is wide Medicaid coverage expansion for HCV treatment nationwide, with the removal of previous eligibility restrictions. However, states vary on specific drugs covered and prior authorization processes. Efforts continue via federal programs and clinical guidelines to further facilitate access and equity in HCV treatment.
Approximately 2.4 million people in the United States have HCV, and newer medications can successfully treat many individuals with the disease. This expansion of Medicaid coverage for HCV treatment is a significant step towards addressing this public health issue and ensuring equitable access to curative therapies.
References:
[1] National Viral Hepatitis Roundtable (NVHR). (2021). Medicaid Coverage of Hepatitis C Treatment: A 50-State Survey. Retrieved from https://www.hepatitisc.org/wp-content/uploads/2021/06/NVHR-Medicaid-HCV-Coverage-Report-2021.pdf
[2] Centers for Disease Control and Prevention (CDC). (2022). Hepatitis C. Retrieved from https://www.cdc.gov/hepatitis/hcv/index.htm
[3] American Liver Foundation. (2022). Hepatitis C: Medication Assistance Programs. Retrieved from https://www.hepatitisc.org/living-with-hepatitis/c/medications/medication-assistance-programs/
[4] Health Resources and Services Administration (HRSA). (2022). Medicaid. Retrieved from https://www.hrsa.gov/get-coverage/medicaid/
[5] Substance Abuse and Mental Health Services Administration (SAMHSA). (2022). Medicaid. Retrieved from https://www.samhsa.gov/medicaid
- Health providers should emphasize that the recent expansion of Medicaid has eliminated fibrosis and sobriety restrictions for hepatitis C treatment, making it easier for patients to access curative therapies, especially those dealing with chronic diseases and various medical conditions.
- As advocacy groups work to facilitate access to hepatics C treatment for low-income individuals via Medicaid, science continues to evolve, with health insurance companies adjusting their formularies to include or exclude certain drugs, such as the removal of several key HCV drugs from the preferred list in Nevada or the addition of Epclusa in South Carolina.
- To ensure that individuals with hepatitis C have access to affordable and fair health-and-wellness resources, organizations like Help-4-Hep, the American Liver Foundation, NeedyMeds, and the Patient Advocate Foundation offer crucial assistance programs that include locating financial resources for HCV treatment, medication discount cards, and resources for managing medical expenses, catering to low-income individuals, the uninsured, and those without government support.
