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Tufts Health Plan lifts restrictions on hepatitis C drugs

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John Tortelli, of Arlington, said he’s pleased with Tufts Health Plan’s policy change, “but I don’t want to jump the gun. I’ll be thrilled when I have the actual meds in my hand.”Dina Rudick/Globe Staff

Tufts Health Plan has lifted restrictions on expensive medications that can cure hepatitis C, and will now pay for the drugs regardless of the condition of infected patients' livers.

The shift in policy comes as health insurers are taking heat for limiting the drugs to people with severe liver damage.

Tufts officials said they adopted the change late last week. But it came to light only Tuesday, after the Globe reported on the difficulty some patients experience getting the medication.

Because people with hepatitis C can live for decades without symptoms, many insurers reserve the drugs for the sickest patients, despite medical guidelines that recommend treating nearly every infected person.


Tufts spokeswoman Sonya Hagopian said the policy change had been under consideration for a long time and was adopted in response to "emerging research and guidance from national medical organizations."

The new policy applies to Tufts' commercial and Medicaid plans.

Among the first to learn of the change was John Tortelli, an Arlington man featured in the Globe story, who was denied the treatment because his liver is only slightly damaged.

Dr. Nezam H. Afdhal, Tortelli's doctor and chief of hepatology at Beth Israel Deaconess Medical Center, said Tufts called his office Tuesday morning advising him of the policy change and asking which drug he would like to prescribe for Tortelli. Afdhal's office informed Tortelli, and Tufts called the patient Tuesday afternoon to tell him his prescription for Harvoni was approved.

"I'm celebrating, but I don't want to jump the gun," said Tortelli, a 64-year-old retiree. "I'll be thrilled when I have the actual meds in my hand."

That could happen as early as next week, if all goes well, according to Annie Vong, a clinical pharmacist who works with Afdhal.

Tortelli stands a greater than 95 percent chance of being cured of the viral infection he acquired during heart surgery in 1978.


Tortelli said he's looking forward to ending the joint aches and mental fogginess the virus causes, "and especially the mental worry about, 'Is my liver going to last?' " An estimated 5 to 20 percent of people infected with hepatitis C eventually develop cirrhosis, and 1 to 5 percent die from liver cancer or cirrhosis.

Most health insurers in Massachusetts have policies requiring evidence of advanced liver disease before they will pay for treatment. That includes the plans that enroll two-thirds of people in MassHealth, the state's Medicaid program.

Some of the plans have other restrictions, such as requiring six or 12 months of abstinence from drugs and alcohol. (Even before the policy change, Tufts did not have a such a requirement.)

Advocates decry such limitations, saying intravenous drug users will continue to spread the virus if they remain untreated.

A notable exception is the state's largest insurer, Blue Cross Blue Shield of Massachusetts, which pays for the drugs regardless of the level of liver damage or the patients' use of illicit drugs.

The hepatitis C drugs have become a flashpoint in a national debate over drug pricing. The first in the class, Sovaldi, was approved in late 2013, with a list price of $84,000 for a 12-week course of treatment. Several other drugs have followed, with list prices ranging from $54,600 to $94,500. But state Medicaid programs and private insurers negotiate significant, and undisclosed, discounts.


A congressional investigation last year concluded that Gilead Sciences Inc., maker of Sovaldi and Harvoni, had priced the drugs for maximal profit, separate from the cost of developing and manufacturing them.

In January, Massachusetts Attorney General Maura Healey warned Gilead its prices "may constitute an unfair trade practice in violation of Massachusetts law."

But Gilead has said it priced the drugs "responsibly and thoughtfully," noting the treatments are actually cheaper and much more effective than the yearlong treatment previously available.

Hepatitis C is spread through blood. Tortelli got it from a transfusion in the years before a screening test for donors was available. But most people with hepatitis C acquired the infection from sharing needles when using intravenous drugs.

As a result, a high proportion of hepatitis C patients are low-income people on Medicaid, or prisoners — making the drug's cost a strain for state budgets.

In most states, Medicaid programs, unable to afford to treat everyone, have set limitations. But the federal government has advised them such restrictions are not allowable.

An estimated 3 million to 5 million Americans, and 67,000 to 100,000 people in Massachusetts, are infected with hepatitis C, although most don't know it.

Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter @felicejfreyer.