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COVERAGE OF VIRAL HEPATITIS SCREENING AND TREATMENT IN MASSACHUSETTS

Prepared by the Center for Health Law and Policy Innovation of Harvard Law School

APRIL 2017

An OveRvIew

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TABLEOFCONTENTS

INTRODUCTION 4

BACKGROUND 4

METHODOLOGY 5

HEALTHINSURANCEPLANS 5ASSESSEDSERVICES 6DATAGATHERING 6

HBVANALYSIS 7

HBVVACCINE 7HBVSCREENINGS 8HBVDRUGCOSTS 10HBVDRUGRESTRICTIONS 11

HCVANALYSIS 12

HCVSCREENINGS 13HCVDRUGCOVERAGE 13HCVDRUGCOSTS 14HCVDRUGRESTRICTIONS 15

CONCLUSION 16

APPENDIXA 18

APPENDIXB 20

HBVDRUGS 20HCVDRUGS 20

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ABOUT THE AUTHORS

TheCenterforHealthLawandPolicyInnovationofHarvardLawSchool(CHLPI)advocatesforlegal,regulatory,andpolicyreformstoimprovethehealthofunderservedpopulations,withafocusontheneedsoflow-incomepeoplelivingwithchronicillnesses.CHLPIworkswith consumers, advocates, community-based organizations, health and social servicesprofessionals, food providers and producers, government officials, and others to expandaccess to high-quality healthcare and nutritious, affordable food; to reduce healthdisparities;todevelopcommunityadvocacycapacity;andtopromotemoreequitableandeffectivehealthcareandfoodsystems.CHLPIisaclinicalteachingprogramofHarvardLawSchoolandmentorsstudentstobecomeskilled,innovative,andthoughtfulpractitionersaswellasleadersinhealth,publichealth,andfoodlawandpolicy.

Coverage of Viral Hepatitis Screening and Treatment in Massachusetts: An Overview iswritten by Michael Cunniff, Shane Hebel, Katie Garfield and Amy Rosenberg. For moreinformation on CHLPI and its prior work regarding health insurance coverage inMassachusetts,pleasevisitwww.chlpi.org.

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The Center for Health Law and Policy Innovation provides information and technical assistance on issues related to health reform, public health, and food law. It does not provide legal representation or advice. This document should not be considered legal advice. For specific legal questions, consult an attorney. Additionally, please note that health insurance plans occasionally alter coverage, associated costs, or restrictions over the course of a plan year. This report is meant to capture trends in benefit coverage at a specific moment in the spring of 2017, and may therefore not be representative of coverage at a later date. Health care providers and plan members should always confirm coverage by contacting the individual plan.

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INTRODUCTION

Despite recent advances in prevention and treatment,HepatitisB (HBV) andHepatitis C(HCV) continue to have significant impact on both individual and public health in theUnited States. This impact is due, inpart, to thebarriers thatprevent infectedor at-riskindividuals from receiving necessary screenings and treatment. This report provides ananalysisofsomeofthesebarriersinMassachusettsbyassessinghealthinsurancecoverageofkeyHepatitisservicesandmedicationsinthestate.ThisanalysisisintendedtosupporttheeffortsoftheMassachusettsDepartmentofPublicHealth(MDPH)andtheCentersforDisease Control and Prevention (CDC) to identify and address the underlying trends inaccesstoHepatitiscare.

Background

TheCDCestimatesthattherearecurrentlybetween850,000and2.2millionpeoplelivingwith chronic HBV in the United States.1 While an HBV vaccine has been commerciallyavailablesincethe1980s,2newinfectionscontinuetooccur,withanestimated19,200newcases occurring in 2014 alone.3 Reported HBV cases have been on the decline inMassachusetts over the last several years, largely due to widespread childhoodimmunizationwith theHBV vaccine.4 In 2015 roughly 119 new cases of acuteHBV and1,851newcasesofchronicHBVwerereportedinthestate.5

HCV also remains a significant national and statewidepublic health concern, despite theavailabilityofnewhighlyeffectivetreatments.TheCDCestimatesthattherewere30,500cases of acute HCV reported in the United States in 2014.6 Approximately 75%-85% ofindividualswhoexperienceanacuteHCVinfectionwilldevelopachronicinfection.7Thusof the 30,500 acute cases reported in 2014, 22,875 – 25,925will likely become chronic.Theywilljointheestimated2.7–3.9millionpeoplewithchronicHCVintheUnitedStates.8InMassachusetts,HCVcaseshave remained fairlyhigh,withbetween roughly8,000and

1HepatitisBFAQsforthePublic,CENTERSFORDISEASECONTROLANDPREVENTION(lastupdatedMay23,2016),https://www.cdc.gov/hepatitis/hbv/bfaq.htm#overview.2HistoryofHepatitisBVaccine,HepatitisBFoundation,http://www.hepb.org/prevention-and-diagnosis/vaccination/history-of-hepatitis-b-vaccine/(lastvisitedMar.21,2017).3HepatitisBFAQsforthePublic,CENTERSFORDISEASECONTROLANDPREVENTION(lastupdatedMay23,2016),https://www.cdc.gov/hepatitis/hbv/bfaq.htm#overview.42015IntegratedHIV/AIDS,STD,andViralHepatitisReport,MADEP’TOFPUBLICHEALTH2(Dec.2016),availableathttp://www.mass.gov/eohhs/docs/dph/cdc/aids/std-surveillance-2015.pdf.5Id.at19,21.6HepatitisCFAQsforthePublic,CENTERSFORDISEASECONTROLANDPREVENTION(lastupdatedOct.17,2016),https://www.cdc.gov/hepatitis/hcv/cfaq.htm#overview.7Id.8Id.

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9,000casesreportedeachyear.9 In2015,9,079casesofacuteHCVwerereported to thestate.10

METHODOLOGY HealthInsurancePlans

The analysis in this report focuses on coverage of Hepatitis screening and treatmentservices in insurance plans that are likely to be particularly relevant to low-income andvulnerable populations in the state, as these populations are likely to face the mostsignificantbarriersinaccessingnecessaryHepatitiscare.Thissectionofthereportoutlinesthereasoningappliedinchoosingtheseplans.Forafulllistoftheplansthatwereanalyzedinordertocreatethisreport,pleaseseeAppendixA.Silver-LevelQualifiedHealthPlans(QHPs)

The first plans analyzed in this report are the silver-levelQualifiedHealth Plans (QHPs)available on the Massachusetts State Marketplace (a/k/a the Massachusetts HealthConnector).Therewere several reasonswhy theseplanswere chosen for analysis. First,every insurerwho sellsQHPsona stateor federally-runMarketplacemustoffer at leastonesilverplan.Asaresult,theseplansaregenerallythemostrepresentativeofcoverageon themarket as a whole. These plans are also typically the best value for low-incomeconsumersbecausemany low-incomeconsumerswhochoose theseplanshaveaccess tobothAdvancedPremiumTaxCreditsandcost-sharingsubsidiestohelpthemtoaffordtheircoverage.Federalcost-sharingsubsidiesareavailableonlyonsilver-levelplans.ConnectorCarePlans

Massachusetts ConnectorCare Plans comprise the second set of plans analyzed in thisreport.TheseplansareuniquetoMassachusetts,andoffersubsidizedcareto individualsand familieswith incomes up to 300%of the Federal Poverty Level.11 These plans havestandardized, low,out-of-pocketcosts forhealthcareservices.12Forexample, individualscurrentlypaynomorethan$50incost-sharingwhenaccessinganycovereddrugthroughaConnectorCareplan.13 92015IntegratedHIV/AIDS,STD,andViralHepatitisReport,MADEP’TOFPUBLICHEALTH22(Dec.2016),availableathttp://www.mass.gov/eohhs/docs/dph/cdc/aids/std-surveillance-2015.pdf.10HepatitisCVirusInfection,SurveillanceReport2007-2015,MADEP’TOFPUBLICHEALTH1(Jan.2017),availableathttp://www.mass.gov/eohhs/docs/dph/cdc/reporting/surveillance-report-hepatitis-c.pdf.11ConnectorCareHealthPlans:Affordable,high-qualitycoveragefromtheHealthConnector,MASSACHUSETTSHEALTHCONNECTOR,https://www.mahealthconnector.org/wp-content/uploads/ConnectorCare_Overview-2017.pdf(lastvisitedMar.23,2017).12Id.13Id.

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ConnectorCareplansareincludedinthisanalysisbecause,likethesilver-levelQHPs,theyareparticularlyattractivetolow-incomepopulationswhomayfacethegreatestdifficultiesinaccessingnecessaryHepatitiscare.MassHealthPlans

The final group of plans analyzed in this report includes programs in MassHealth,Massachusetts’s Medicaid program. MassHealth offers a variety of coverage options,dependinguponapplicanteligibility.CoverageintheseplansmaybeprovideddirectlybyMassHealth(throughtheMassHealthPrimaryCareClinicianPlan(PCCP)),orbyManagedCare Organizations (MCOs) contracting with MassHealth. MassHealth plans have beenincludedinthisanalysisastheyareaparticularlyimportantsourceofinsurancecoverageforthelowestincomeresidentsofthestate.Theanalysisinthisreportspecificallylooksatthe MassHealth coverage options that are available to the majority of MassHealthparticipants, including: MassHealth Standard, CommonHealth, Family Assistance, andCarePlus plans.14 The analysis does not, however, include some ofMassHealth’s smallerprogramstargetedatindividualseligibleforbothMedicareandMedicaidandseniors(i.e.,OneCareandSeniorCareOptions).15AssessedServices

To assess the current status of access to care inMassachusetts, this report analyzes thecoverageofkeyHBVandHCV(1)screeningservices,(2)vaccinations(HBVonly),and(3)prescriptiondrugs.ThelistofdrugsanalyzedwasdevelopedincollaborationwiththeNational ViralHepatitis Roundtable (NVHR). All drugs recommended for analysis by theNVHRare included in thisanalysis. Specifically, this reportanalyzescoverageofallFDA-approvedHBVdrugs16 andkeydirect-acting antiviral drugs approved foruse in treatingHCV.AfulllistoftheanalyzeddrugscanbefoundinAppendixB.DataGathering

Thedata in thisreportwasgathered fromJanuary31,2017throughMarch24,2017.Togather thedata,assessorsconsultedpublicly-available insurancedocumentsavailablevia

14Formoreinformationontheseoptions,seeMassHealthCoverageTypes,Exec.OfficeofHEALTHANDHUMANSERVICES,http://www.mass.gov/eohhs/consumer/insurance/masshealth-coverage-types/masshealth-coverage-types.html.15NotethatthisanalysisexcludesoneMassHealthMCO—NeighborhoodHealthPlan(NHP)—fromitsanalysisofcoverageoftheHBVvaccineandscreenings.ThisisnotmeanttoindicatethatNHPdoesnotcovertheseservices,butinsteadthatNHPcustomerservicerepresentativescouldnotadequatelyrespondtoassessorquestionsregardingtheseservices.AssessorswereabletoanalyzeNHP’scoverageofHBVandHCVmedications,andsothatdataisincludedinthisanalysis.16DrugWatch:CompoundsinDevelopmentforChronicHepatitisB,HEPATITISBFoundation(lastupdatedMar.2017),http://www.hepb.org/treatment-and-management/drug-watch/.

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theMassachusettsHealthConnectorandindividualinsurerwebsites.Wherethisdatawasnot available or accessible online, assessors confirmed coverage information by callinginsurer customer service representatives. In many cases, insurers were called multipletimestoensureconsistentanswersaboutcoverageforspecificdrugsorservices.Assessorsalsoengagedinrepeatedcallswheninconsistenciesappearedbetweenonlineformulariesandstatementsmadebycustomerservicerepresentatives,particularly fordrugsthatdidnotappearontheformulariesbutwerereportedbyrepresentativestoactuallybecovered.Informationwasrecordedaboutcoverage,cost-sharing,andotheraspectsofcoveragethatcouldcreatebarrierstoaccess.Thesepotentialbarriersincludedthefollowingutilizationmanagement restrictions: prior authorization, step therapy, and quantity limitrequirements.Thesetermsaredefinedasfollows:

• PriorAuthorization:Requiringplanmemberstoobtainapproval fromthehealthplanpriortoreceivingcoverageforamedicationorotherservice.17

• StepTherapy:Requiringplanmembersto try lessexpensivemedicationsto treattheirconditionsbefore“steppingup”tomoreexpensivemedications.18

• QuantityLimits:Limitingthequantityofadrugthataplanmembercanaccessinagiventimeperiod.19

ThefulldatafromtheplananalysiscanbefoundinAttachmentsI,II,andIII.

HBVANALYSIS Assessors reviewedMassachusetts QHPs, ConnectorCare plans, andMassHealth plans toidentify trends in coverage and cost-sharing for the HBV vaccine, screenings, and keymedications.Overall,assessorsfoundthatmostoftheassessedservicesarecoveredbytheplanswithlowcost-sharingobligations.TheHBVvaccineandscreeningsarecoveredbyallplans analyzed. Similarly, assessed medications are generally available across insurers,albeit with variations in drug costs and utilization management restrictions. A detailedanalysisofeachofthesetrendsisprovidedbelow.HBVVaccine Since1991, routinevaccinationofchildrenhasbeenrecommended for thepreventionofHBV.20 InMassachusetts, theHBV vaccine is required for all children, though exceptions

17PriorAuthorization,HEALTHCARE.GOV,https://www.healthcare.gov/glossary/prior-authorization/(lastvisitedMar.23,2017).18Whatispriorauthorization,steptherapy,andquantitylimit?,EHEALTHMEDICARE(lastupdatedOct.15,2016)https://www.ehealthmedicare.com/faq-what-are-prior-authorizations-quantity-limits-and-step-therapy/.19Id.

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can be made to accommodate religious beliefs.21 Under the Affordable Care Act (ACA),insurersoperatingintheindividualmarketmustcoverimmunizationsrecommendedanddetermined to be for routine use by theAdvisoryCommittee on ImmunizationPractices(ACIP).22ACIPhasrecommendedtheHBVvaccineforallinfantsandmanyothercategoriesofindividuals.23AlloftheassessedinsurersprovidecoveragefortheHBVvaccinewithoutcost-sharing.HBVScreeningsUnder theAffordableCareAct (ACA), insurers operating in the individualmarket and inMedicaidexpansionplansmustcoverpreventivecareservicesgivenanAorBratingbytheU.S.PreventiveServicesTaskForce(USPSTF)withnocost-sharingfortheconsumer.24ForHBV, the USPSTF recommends screening for HBV as a preventive measure in twoscenarios:(1)forpeopleathighriskofinfection,and(2)forpregnantwomenduringtheirfirst prenatal visit.25 The assessed insurers appear to follow these guidelines anddonotincludeanycost-sharingelements for theseservices.However,several insurers indicatedthat they may apply cost-sharing on diagnostic screenings when the screening is notconsidered to be preventive. All of these diagnostic cost-sharing requirements appear insilver-levelQHPs.NoneoftheanalyzedConnectorCareorMassHealthplansindicatedthattheyapplyacost-sharingrequirementforanysortofHBVscreening.HBVDrugCoverage

AccordingtotheHepatitisBFoundation,theU.S.FoodandDrugAdministration(FDA)hasapproved 8 drugs for the treatment of HBV,26 some of which also have a genericformulation available. Plan assessors found that there is fairly robust coverage of theseHBVmedications inMassachusetts.More specifically, the analysis revealed the followingfourpoints:

20HepatitisBFAQsforHealthProfessionals,CENTERSFORDISEASECONTROLANDPREVENTION(lastupdatedAug.4,2016),https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm.21MassachusettsStateVaccineRequirements,NATIONALVACCINEINFORMATIONCENTER(Mar.21,2017),http://www.nvic.org/vaccine-laws/state-vaccine-requirements/massachusetts.aspx.22PreventiveServicesCoveredbyPrivateHealthPlansundertheAffordableCareAct,THEHENRYJ.KAISERFAMILYFOUNDATION(Aug.4,2015),http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/;PublicLaw111-148PATIENTPROTECTION&AFFORDABLECAREACT(2010),§§2713.23HepatitisBFAQsforHealthProfessionals,CENTERSFORDISEASECONTROLANDPREVENTION(lastupdatedAug.4,2016),https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm.24PreventiveServicesCoveredbyPrivateHealthPlansundertheAffordableCareAct,THEHENRYJ.KAISERFAMILYFOUNDATION(Aug.4,2015),http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/;PublicLaw111-148PATIENTPROTECTION&AFFORDABLECAREACT(2010),§§2713,2001.25USPSTFAandBRecommendations,U.S.PREVENTIVESERVICESTASKFORCE(June2016),https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/.26DrugWatch:CompoundsinDevelopmentforChronicHepatitisB,HepatitisBFoundation,http://www.hepb.org/treatment-and-management/drug-watch/(lastvisitedMar.23,2017).

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1) Thefollowingmedicationsarecoveredbyatleast80%oftheanalyzedplans

SilverPlans ConnectorCarePlans MassHealthPlansAdefovirdipivoxil

BaracludeEntecavirEpivirIntronA

LamivudinePegasysViread

AdefovirdipivoxilEntecavirIntronA


AdefovirdipivoxilBaracludeEntacavirIntronA


2) Thefollowingmedicationsarecoveredbybetween50and80%oftheanalyzed

plans

SilverPlans ConnectorCarePlans MassHealthPlansTyzekaVemlidy

BaracludeEpivirTyzeka

EpivirHepseraTyzeka

3) Thefollowingmedicationsarecoveredinlessthanhalfoftheanalyzedplans

SilverPlans ConnectorCarePlans MassHealthPlansHepsera Hepsera

VemlidyVemlidy

4) There are no assessedmedications that are covered by none of the analyzed

plansThe coverage analysis also identified several noteworthy trends. First, across all of theassessed markets, new drugs (such as Vemlidy, which was approved by the FDA inNovember201627)are covered lessoften thandrugs thathavebeenon themarket foralonger period of time. Additionally, drugs with generic formulations available, such asHepsera and Epivir, are covered less often than brand name drugs without generics.Notably,assessorsalsofoundanumberofinconsistenciesbetweenonlineformulariesandcustomerservicerepresentativestatementsregardingcoverageofseveraldrugs,includingHepsera, adefovir dipivoxil, and Vemlidy. These discrepancies suggest that the online

27PressRelease,U.S.FoodandDrugAdministrationApprovesGilead’sVemlidy®(TenofovirAlafenamide)fortheTreatmentofChronicHepatitisBVirusInfection,GILEAD(Nov.10,2016),http://www.gilead.com/news/press-releases/2016/11/us-food-and-drug-administration-approves-gileads-vemlidy-tenofovir-alafenamide-for-the-treatment-of-chronic-hepatitis-b-virus-infection.

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formulariesmaynotbefullyup-to-datewithplanpolicies,whichmaycreateconfusionforconsumers.

HBVDrugCosts

Even covered drugs can become essentially inaccessible to low-income consumers ifinsurers impose high cost-sharing via high copay or coinsurance requirements. PlacingHBVmedications on formulary tiers that impose coinsurance requirements is especiallyproblematicbecauseofthehighstickerpriceofmostHBVdrugs.Forexample,accordingtoone analysis, Pegasys is currently priced at roughly $37,000 for a 48 week supply.28 Ifpatients have to pay even a relatively small 20% coinsurance, they would have tocontribute $7,400 topay for their “covered”drug (orpay aportionof that amountuntilthey hit their out-of-pocket maximum). For that reason, it is preferable for insurers toapply copay requirements for HBV drugs, as copay requirements limit cost-sharing to apre-determinedamountwhich isoften significantly less thanwouldbe requiredunderacoinsurancerequirement.

MostMassachusettsinsurersofferatleastsomeplansthathavecopaysevenforspecialtydrugs, thereby significantly reducing the cost to consumers. Five of the eighteen QHPsanalyzed required coinsurance payments for most of the assessed HBV drugs. AllMassHealthandConnectorCareplansrequirecopaysforalldrugs.Whilethesecopaysarealwaysminimal forMassHealthplans (i.e., $3.65or less), they canvary slightlymore forConnectorCareplans,wherecopaysrangefrom$1-$50dependingonthetypeofplanandformulary tier on which the drug appears. Encouragingly, all QHP insurers that offeredplanswithcoinsurancerequirementsalsoofferedsimilarplansthatonlyrequiredcopaysforthesamedrugs,whichmeansthatconsumerswhoneedexpensivedrugs,likeHepatitisdrugs,canstillselectaplanfromtheirpreferredinsurer.

OftheQHPsthatrequiredcopays,nonerequiredacopayfortheassesseddrugsthatwashigher than $110. Thus, so long as they purchase a planwith copays, consumers on theindividualmarketpayamaximum$1,320foranHBVdrugduringtheyear.

Beloware the rangesof copays required forHBVdrugs in theMassachusetts silver-levelQHPs.

28Peginterferonalfa-2A,HEPATITISCONLINE,http://www.hepatitisc.uw.edu/page/treatment/drugs/peginterferon-alfa-drug(lastvisitedMar.23,2017).Note that this figure reflects the wholesale price, individual insurers may receive mandatory or negotiated rebates, causing prices to vary.

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HBVMedicationCopayRanges:Silver-LevelQHPs• IntronA($0-$90)• Pegasys($50-$110)• Epivir($60-$90)• lamivudine($13-$35)• Hepsera($60-$90)• adefovirdipivoxil($13-$90)

• Baraclude($60-$90)• entecavir($13-$90)• Tyzeka($60-$90)• Viread($30-$80)• Vemlidy($60-$90)

Asnotedabove,MassHealthandConnectorCareplanshave lowerandmorestandardizedcopays. MassHealth plans require copays of $3.65 or less for all drugs. ConnectorCarecopaysrangefrom$1-$50basedonlevelofplanandtierofdrug.

HBVDrugRestrictions

Almostalloftheassessedplansuseutilizationmanagementrequirementstorestrictaccessto HBV drugs in some way. Restrictions placed on HBV medications include: priorauthorization,steptherapy,andquantitylimits.Theserestrictionsareconcerningbecausethey serve to limit access, and can create gaps in coverage for consumers who havedifficultyovercomingtheadministrativeorpracticalhurdlestheycreate.Forexample,bothpriorauthorizationandstep therapyrequirementscandelay theamountof time it takesforanindividualtogetamuchneededmedication,whichcanimpacthealthoutcomes.

The summary below highlights which drugs are subject to utilization managementrestrictions in each plan category, and the frequency with which those restrictions areapplied.

1a) PriorAuthorization(PA)–DrugsRequiringPAinatLeast1Plan


BaracludeEntecavirEpivirHepsera

LamivudineIntronAPegasysTyzekaVemlidy

AdefovirdipivoxilBaracludeEntecavirEpivirHepsera

LamivudineIntronAPegasysTyzekaVemlidy


LamivudineIntronAPegasysTyzekaVireadVemlidy

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1b) PriorAuthorization(PA)–DrugsRequiringPAin50%orMoreofPlans

SilverPlans ConnectorCarePlans MassHealthPlans Pegasys Pegasys

2) StepTherapy(ST)–DrugsRequiringSTinatLeast1Plan

SilverPlans ConnectorCarePlans MassHealthPlansBaraclude Baraclude Adefovirdipivoxil

Baraclude*Note:NoassessedHBVdrugsrequireSTin50%orMoreofPlans

3a) QuantityLimits(QL)–DrugsRequiringQLinatLeast1Plan


BaracludeEntecavirEpivirHepsera

LamivudineIntronAPegasysTyzekaViread





3b) QuantityLimits(QL)–DrugsRequiringQLin50%orMoreofPlans

SilverPlans ConnectorCarePlans MassHealthPlansPegasys Pegasys Pegasys

Both prior authorization requirements and quantity limits were fairly pervasive in theassessed plans, affecting almost all of the drugs that were analyzed.With newer drugs,priorauthorizationwasalmostalwaysaguarantee—especiallyifthedrugdidnotshowupontheformularybutiscoveredasperacustomerservicerepresentative.

HCVANALYSIS AssessorsalsoreviewedMassachusettsQHPs,ConnectorCareplans,andMassHealthplansto identify trends in coverage and cost-sharing forHCV screenings and keymedications.AssessorsfoundthatHCVscreeningsarecoveredbyalloftheassessedplans.Additionally,whilecostsvaried,coverageofHCVmedicationswasfoundtoberelativelyrobustacross

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insurers, albeitwith frequent application of utilizationmanagement restrictions. Each ofthesetrendsisanalyzedinmoredetailbelow.HCVScreenings

TheUSPSTFrecommendsscreeningforHCVasapreventivemeasureintwoscenarios:(1)for people at high risk of infection, and (2) as a one-time screening for all adults bornbetween 1945 and 1965.29 Following USPSTF guidance, every insurer analyzed coverspreventiveHCVscreeningswithoutcost-sharing.SomeinsurersechoedthelanguageoftheUSPSTF in indicating which populations were eligible for free HCV screenings. Othersindicated such screenings would be available for free “when medically necessary.”Regardlessoftheactual language, itappearsthat insurersinMassachusettsarefollowingUSPSTFguidancewithrespecttoHCVscreenings.HCVDrugCoverage

Therecentdevelopmentofhighlyeffectivedirect-actingantiviraldrugsforthetreatmentofHCVhasthepotentialtosignificantlyimprovehealthoutcomesformanyindividualslivingwithHCV.However,nationallytherehasbeenatrendtowardsrestrictingaccesstothesemedications due to the high prices charged by pharmaceutical manufacturers. As notedabove,assessorsanalyzedcoverageofsevendirect-actingantiviralmedicationscommonlyprescribed to treat HCV – Daklinza, Sovaldi, Harvoni, Viekira Pak, Epclusa, Olysio, andZepatier.Theanalysisrevealedthefollowingcoveragetrends:1) Thefollowingmedicationsarecoveredbyatleast80%oftheanalyzedplans

SilverPlans ConnectorCarePlans MassHealthPlansEpclusaHarvoniSovaldiZepatier

EpclusaHarvoniSovaldi

ViekiraPak

DaklinzaEpclusaHarvoniSovaldi

2) Thefollowingmedicationsarecoveredbybetween50and80%oftheanalyzedplans

SilverPlans ConnectorCarePlans MassHealthPlansDaklinzaOlysio

ViekiraPak

DaklinzaOlysioZepatier

OlysioViekiraPakZepatier

29U.S.PREVENTIVESERVICESTASKFORCE,supranote25.

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Many of the assessed HCV medications are widely covered by Massachusetts insurers,givingconsumersoptionswhensearchingforaninsuranceplanthatbestsuitstheirneeds.However,itisimportanttonotethateffectivenessofthesemedicationscanvarybypatient.ThusitisstillconcerningthatDaklinza,Olysio,ViekiraPak,andZepatierareexcludedfromcoverageinmanyplans.

HCVDrugCosts

Manyinsurersacrossthenationhaveimposedhighcost-sharingonHCVmedications,likelyin response to the high prices that insurers face in purchasing these drugs frompharmaceutical manufacturers. In many cases this cost-sharing comes in the form ofcoinsurance requirements. Putting HCV medications on formulary tiers that imposecoinsurance requirements is especially problematic because of the high price of thesemedications.Forexample, Sovaldiwaspricedat $84,000 for the full courseof treatmentwhen it was first introduced.30 If patients are subject to even a relatively small 20%coinsurance requirement, they would have to contribute more than $15,000 to pay fortheir “covered” drug (or pay a portion of that amount until they hit their out-of-pocketmaximum).Forthatreason,itisextremelyimportantthatHCVdrugsbeavailableonplansthatapplycopays,ratherthancoinsurancerequirements.

As noted above,mostMassachusetts insurers offer at least someplans that have copaysevenforspecialtymedications,therebysignificantlyreducingthecosttoconsumers.Fiveofthe18QHPsanalyzedrequirecoinsurancepaymentsformostoftheassessedHCVdrugs.AllMassHealthandConnectorCareplans requirecopays, ranging from$1-$50dependingon plan type and formulary tier. Encouragingly, all QHP insurers that offer plans withcoinsurance also offer similar plans that only require copays for high-tier drugs, whichmeans that consumerswhoneed expensive drugs, likeHCVdrugs, can still select a planfromtheirpreferredinsurer.

Of theQHPsthatrequiredcopays,nonerequiredacopayofhigher than$110.BelowaretherangesofcopaysrequiredforHCVdrugsintheassessedQHPs.

HCVMedicationCopayRanges:Silver-LevelQHPs• Epclusa($30-$110)• Harvoni($30-$110)• Olysio($50-90)• Sovaldi($30-$110)

• ViekiraPak($50-90)• Zepatier($50-$110)• Daklinza($50-110)

30OlgaKhazan,TheTrueCostofanExpensiveMedication,THEATLANTIC(Sept.25,2015)https://www.theatlantic.com/health/archive/2015/09/an-expensive-medications-human-cost/407299/. Note that this figure reflects the original wholesale price, individual insurers may receive mandatory or negotiated rebates, causing prices to vary.

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AswithHBVmedications,thisrangeofcopaysmeansthat,solongastheypurchaseaplanwithcopays,consumersontheindividualmarketwillpayamaximum$1,320foranHCVdrugduringtheyear.Asnotedabove,MassHealthandConnectorCareplanshave lowerandmorestandardizedcopays. MassHealth plans require copays of $3.65 or less for all drugs. ConnectorCarecopaysrangefrom$1-$50basedonlevelofplanandtierofdrug.HCVDrugRestrictions

All analyzed plans use utilization management requirements to restrict access to HCVdrugsinsomeway.RestrictionsplacedonHCVinclude:priorauthorization,steptherapy,andquantitylimits.Asnotedabove,theserestrictionsareconcerningbecausetheyservetolimitaccess,andcancreategapsincoverageforconsumerswhohavedifficultyovercomingthe administrative or practical hurdles they create. For example, some insurers imposeparticularlyburdensomeprior authorization requirements, includingobtaining a requestfromaspecialist,showingabstinencefromsubstanceabuse,anddemonstratingsignificantliverdamage.These restrictionsonaccess candelayaccess to care,ultimately leading toworsehealthoutcomesforconsumers.The summary below highlights which drugs are subject to utilization managementrestrictions in each plan category, and the frequency with which those restrictions areapplied.1) PriorAuthorization(PA)–DrugsRequiringPAin50%orMoreofPlans

SilverPlans ConnectorCarePlans MassHealthPlansDaklinzaEpclusaHarvoniOlysioSovaldi

ViekiraPakZepatier

DaklinzaEpclusaHarvoniOlysioSovaldi

ViekiraPakZepatier


ViekiraPakZepatier

*Note:AllHCVdrugsrequirePAinatleast50%ofplans.ThereforenotableregardingdrugsrequiringPAinatleast1planisincludedinthisreport,asthetablewouldmirrorthetableabove.

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2) StepTherapy(ST)–DrugsRequiringSTinatLeast1Plan

SilverPlans ConnectorCarePlans MassHealthPlans Olysio(PCCplanonly)31

ViekiraPak(PCCplanonly)Zepatier(PCCplanonly)

*Note:NoneoftheassessedHCVdrugsrequireSTin50%ormoreofplans.3) QuantityLimits(QL)–DrugsRequiringQLinatLeast1Plan

SilverPlans ConnectorCarePlans MassHealthPlansDaklinzaEpclusaHarvoniOlysioSovaldi

ViekiraPakZepatier


ViekiraPakZepatier


ViekiraPakZepatier

*Note:NoneoftheassessedHCVdrugsrequireQLin50%ormoreofplans.Notably,alloftheassessedHCVmedicationshavepriorauthorizationrequirements,whichmaydelay or prevent access for individuals livingwithHCV. It is encouraging, however,thatatleasttwoinsurers–BlueCrossBlueShieldandTuftsHealthPlan–haveannouncedthat they will no longer apply prior authorization restrictions related to fibrosis scorewhencoveringHCVmedicationsintheirplans.32Similarly,MassachusettsnolongerallowsMassHealth MCOs to apply prior authorization restrictions related to fibrosis score,substance use abstinence, or prescriber specialty when covering HCV medications.33 Bylimiting the scope of prior authorization requirements in this way, these plans provideimprovedaccesstocrucialHCVtreatmentformanylow-incomeindividualsinthestate.

CONCLUSIONBothHCVandHBVdrugsaregenerallywidelyavailable inMassachusetts,regardlessofapatient’s income.QHPsaresplitonwhethertheyofferdrugsontiersrequiringcopaysorcoinsurance, but generally favored copays, which are preferable for consumers when 31MassHealthidentifiescertainHCVdrugsas“Preferred”andrequirestrialofthatdrug(oraclinicalrationalefornotdoingso)priortouseofnon-preferreddrugs.Thisassessmentthereforeinterpretsnon-preferreddrugsasrequiringsteptherapy.32FeliceJ.Freyer,TuftsHealthPlanLiftsRestrictionsonHepatitisCDrugs,BOSTONGLOBE(Apr.20,2016),https://www.bostonglobe.com/metro/2016/04/19/tufts-health-plan-lifts-restrictions-hepatitis-drugs/2EdZqgl8nXArTmA74fWOLN/story.html.33SeeDanielTsai,MassHealthManagedCareOrganizationBulletin6(July2016),availableathttp://www.mass.gov/eohhs/docs/masshealth/bull-2016/mco-6.pdf.

17

dealingwithexpensivemedications,suchasthoserequiredforthetreatmentofHepatitis.Thosethatdidoffercopayskeptthemat$110orbelow.Massachusetts'sMedicaidprogramoffers similar levels of coverage of these drugs as private insurerswith only low copayrequirements.Thestate’suniqueConnectorCareprogramsalsoofferanaffordablewayforlow-incomeresidents toaccessHBVandHCVdrugs,withcopays thatdonotexceed$50foralldrugs.

Thisisnottosay,however,thattherearenohurdlesthatconsumersmustnavigatewhensearchingfortheplanthatbestmeetstheirneeds.ResidentslookingforcoverageofHCVandHBVdrugsmust carefully examinepotential plans to identify options that cover thespecificmedicationsthattheirprovidersrecommendfortheirtreatment,includingnewerandmore expensivedrugs (such as Zepatier orVemlidy) forwhich access is oftenmorerestricted.Theymustalsocloselyanalyzeeachplan’scoveragedocumentstoensuretheyselect a plan with affordable cost-sharing requirements, such as copay, rather thancoinsurance,requirementsforexpensivedrugs.

These hurdles and other restrictions, like prior authorization and quantity limitrequirements, serve to limit utilization of these drugs and can create gaps in coverage,leading to worse health outcomes both at the individual level and in the broaderpopulation.Asnewcasesofthesediseasescontinuetooccur,itisimportanttomakeaccessto HBV and HCV drugs as widely and easily available as possible in order to protectvulnerablepopulations.

18

APPENDIXA

Thefollowingplanswereassessedindevelopingthisreport:

Silver-LevelQHPs• AmbetterBalancedCare14• AccessBlueBasic(BCBSofMA)• BMCHealthNetPlanSilverA• BMCHealthNetPlanSilverB• FallonHealthCommunityCareSilverCoinsurance35%• FallonHealthDirectCareSilverConnector• FallonHealthSelectCareSilverCoinsurance35%• FallonHealthSelectCareSilverConnector• StandardSilver(HarvardPilgrim)• CoreCoverageHMO1750(HarvardPilgrim)• HNESilverA• MyDocHMOSilverBasic(Minuteman)• MyDocHMOSilverPlus(Minuteman)• NHPPrimeHMO2000/400030/5035%FlexRX4-Tier• HNPPrimeHMO2000/400030/50FlexRX4-Tier• TuftsHealthDirectSilver2000• TuftsHealthDirectSilver2200withCoinsurance• TuftsHealthPremierSilver2000

ConnectorCarePlans• ConnectorCare1(Ambetter)• ConnectorCare2(Ambetter)• ConnectorCare3(Ambetter)• ConnectorCareZero(BMCHealthnet)• ConnectorCareZeroSilver(BMCHealthnet)• ConnectorCarePlanTypeI(BMCHealthnet)• ConnectorCarePlanTypeII(BMCHealthnet)• ConnectorCarePlanTypeIII(BMCHealthnet)• CommunityCarePlanTypeI(Fallon)• CommunityCarePlanTypeII(Fallon)• CommunityCarePlanTypeIII(Fallon)• ConnectorCare1(HNE)• ConnectorCare2(HNE)

19

• ConnectorCare3(HNE)• MyDocHMOConnectorCare1(Minuteman)• MyDocHMOConnectorCare2(Minuteman)• MyDocHMOConnectorCare3(Minuteman)• NHPPrimeHMOConnectorCare0/0• NHPPrimeHMOConnectorCare10/18• NHPPrimeHMOConnectorCare15/22• DirectConnectorCarePlanTypeI(Tufts)• DirectConnectorCarePlanTypeII(Tufts)• DirectConnectorCarePlanTypeIII(Tufts)

MassHealthPlans

• MassHealthPrimaryCareClinicianPlan(PCCP)• BMCHealthNet• CeltiCareHealth• FallonHealth• HealthNewEngland(HNE)• NeighborhoodHealthPlan(NHP)• TuftsHealthPlan

20

APPENDIXBHBVDrugsThefollowingHBVdrugswereassessedindevelopingthisreport:

• IntronA(Interferonalfa-2b)• Pegasys(Peginterferonalfa-2a)• Epivir(lamivudine)• lamivudine• Hepsera(Adefovirdipivoxil)• adefovirdipivoxil• Baraclude(entecavir)• entecavir• Tyzeka(telbivudine)• Viread(tenofovir)• Vemlidy(tenofoviralafenamide/TAF)

HCVDrugsThefollowingHCVdrugswereassessedindevelopingthisreport:

• Daklinza(daclatasvir)• Epclusa(sofosbuvir/velpatasvir)• Harvoni(ledipasvir,sofosbuvir)• Olysio(simeprevir)• Sovaldi(sofosbuvir)• ViekiraPak(ombitasvir,paritaprevir,ritonavir)• Zepatier(elbasvirandgrazoprevir)

1

ATTACHMENTI:HEPATITISVACCINATIONANDSCREENINGCOVERAGEDATA

MASSACHUSETTSSILVER‐LEVELQUALIFIEDHEALTHPLANSAbbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy

HepatitisBVaccine HepatitisBScreening HepatitisCScreening

PlanName Covered(Y/N) Cost Covered

(Y/N) Cost Comments Covered(Y/N) Cost Comments

AmbetterBalancedCare14 Yes $0 Yes $0 Yes $0 AccessBlueBasic(BCBSof

MA) Yes $0 Yes $0 Preventive–coveredwithoutcost‐sharing;diagnostic‐$25copay Yes $0 Preventive–coveredwithoutcost‐sharing;

diagnostic‐$25copayBMCHealthNetPlanSilverA Yes $0 Yes $0 “whenmedicallynecessary” Yes $0 “whenmedicallynecessary”BMCHealthNetPlanSilverB Yes $0 Yes $0 “whenmedicallynecessary” Yes $0 “whenmedicallynecessary”FallonHealthCommunity

CareSilverCoinsurance35% Yes $0 Yes $0 Preventive–fullycovered;Diagnostic–afterdeductible Yes $0 Preventive–fullycovered;Diagnostic–

afterdeductibleFallonHealthDirectCare

SilverConnector Yes $0 Yes $0 Preventive–fullycovered;Diagnostic–afterdeductible Yes $0 Preventive–fullycovered;Diagnostic–

afterdeductibleFallonHealthSelectCareSilverCoinsurance35% Yes $0 Yes $0 Preventive–fullycovered;Diagnostic

–afterdeductible Yes $0 Preventive–fullycovered;Diagnostic–afterdeductible

FallonHealthSelectCareSilverConnector Yes $0 Yes $0 Preventive–fullycovered;Diagnostic

–afterdeductible Yes $0 Preventive–fullycovered;Diagnostic–afterdeductible

StandardSilver(HarvardPilgrim) Yes $0 Yes $0 Preventiveservicesdesignatedbythe

ACAarecoveredwithnocharge Yes $0 PreventiveservicesdesignatedbytheACAarecoveredwithnocharge

CoreCoverageHMO1750(HarvardPilgrim) Yes $0 Yes $0 Preventiveservicesdesignatedbythe

ACAarecoveredwithnocharge Yes $0 PreventiveservicesdesignatedbytheACAarecoveredwithnocharge

HNESilverA Yes $0 Yes $0 Alladultsathighrisk;pregnantwomen Yes $0 Adultsatincreasedrisk,andoncefor

everyonebornbetween1945‐65MyDocHMOSilverBasic

(Minuteman) Yes $0 Yes $0 Adultsathighriskforinfection;pregnantwomenatfirstprenatalvisit Yes $0 Peopleathigh‐risk,andone‐timescreening

foreveryonebornbetween1945‐1965MyDocHMOSilverPlus

(Minuteman) Yes $0 Yes $0 Adultsathighriskforinfection;pregnantwomenatfirstprenatalvisit Yes $0 Peopleathigh‐risk,andone‐timescreening

foreveryonebornbetween1945‐1965

2




NHPPrimeHMO2000/400030/5035%FlexRX4‐tier Yes $0 Yes $0 Pregnantwomen Yes $0

TheUSPSTFrecommendsscreeningforhepatitisCvirus(HCV)inpersonsathighriskforinfection.TheUSPSTFalso

recommendsofferingone‐timescreeningforHCVinfectiontoadultsbornbetween1945and

1965.

NHPPrimeHMO2000/400030/50FlexRX4‐Tier Yes $0 Yes $0 Pregnantwomen Yes $0



1965.

TuftsHealthDirectSilver2000 Yes $0 Yes $0 “personsathighrisk” Yes $0

“Personsathighriskforinfectionoraone‐timescreeningforadults

bornbetween1945and1965“

TuftsHealthDirectSilver2200withCoinsurance Yes $0 Yes $0 “personsathighrisk” Yes $0


bornbetween1945and1965“

TuftsHealthPremierSilver2000 Yes $0 Yes $0 “personsathighrisk” Yes $0


bornbetween1945and1965“CONNECTORCAREPLANSAbbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy




ConnectorCare1(Ambetter) Yes $0 Yes $0 Yes $0 ConnectorCare2(Ambetter) Yes $0 Yes $0 Yes $0

3




ConnectorCare3(Ambetter) Yes $0 Yes $0 Yes $0 ConnectorCareZero(BMCHealthNet) Yes $0 Yes $0 “whenmedicallynecessary” Yes $0 “whenmedicallynecessary” ConnectorCareZeroSilver(BMCHealthNet) Yes $0 Yes $0 “whenmedicallynecessary” Yes $0 “whenmedicallynecessary”

ConnectorCarePlanTypeI(BMCHealthNet) Yes $0 Yes $0 “whenmedicallynecessary” Yes $0 “whenmedicallynecessary”

ConnectorCarePlanTypeII(BMCHealthNet) Yes $0 Yes $0 “whenmedicallynecessary” Yes $0 “whenmedicallynecessary”

ConnectorCarePlanTypeIII(BMCHealthNet) Yes $0 Yes $0 “whenmedicallynecessary” Yes $0 “whenmedicallynecessary”

CommunityCarePlanTypeI(Fallon) Yes $0 Yes $0 Yes $0

CommunityCarePlanTypeII(Fallon) Yes $0 Yes $0 Yes $0

CommunityCarePlanTypeIII(Fallon) Yes $0 Yes $0 Yes $0

ConnectorCare1(HNE) Yes $0 Yes $0 Alladultsathighrisk;pregnantwomen Yes $0 Adultsatincreasedrisk,andoncefor

everyonebornbetween1945‐65ConnectorCare2(HNE) Yes $0 Yes $0 Alladultsathighrisk;pregnant

women Yes $0 Adultsatincreasedrisk,andonceforeveryonebornbetween1945‐65

ConnectorCare3(HNE) Yes $0 Yes $0 Alladultsathighrisk;pregnantwomen Yes $0 Adultsatincreasedrisk,andoncefor

everyonebornbetween1945‐65MyDocHMOConnectorCare1(Minuteman) Yes $0 Yes $0 Adultsathighriskforinfection;

pregnantwomenatfirstprenatalvisit Yes $0 Peopleathigh‐risk,andone‐timescreeningforeveryonebornbetween1945‐1965

MyDocHMOConnectorCare2(Minuteman) Yes $0 Yes $0 Adultsathighriskforinfection;


MyDocHMOConnectorCare3(Minuteman) Yes $0 Yes $0 Adultsathighriskforinfection;


NHPPrimeHMOConnectorCare0/0 Yes $0 Yes $0 Pregnantwomen Yes $0



1965.

4




NHPPrimeHMOConnectorCare10/18

Yes $0 Yes $0 Pregnantwomen Yes $0



1965.NHPPrimeHMOConnectorCare15/22

Yes $0 Yes $0 Pregnantwomen Yes $0



1965.DirectConnectorCarePlanTypeI(Tufts) Yes $0 Yes $0 “personsathighrisk” Yes $0


bornbetween1945and1965“DirectConnectorCarePlanTypeII(Tufts) Yes $0 Yes $0 “personsathighrisk” Yes $0


bornbetween1945and1965“DirectConnectorCarePlanTypeIII(Tufts) Yes $0 Yes $0 “personsathighrisk” Yes $0


bornbetween1945and1965“MASSHEALTHPLANSAbbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy




MassHealthPCCP Yes $0 Yes $0 Yes $0 BMCHealthNet Yes $0 Yes $0 “whenmedicallynecessary” Yes $0 “whenmedicallynecessary”

5




CeltiCareHealth Yes $0 Yes $0 Yes $0 FallonHealth Yes $0 Yes $0 Yes $0

HNE Yes $0 Yes $0 Alladultsathighrisk/pregnantwomen Yes $0 Adultsatincreasedrisk,andoncefor

everyonebornbetween1945‐65

TuftsHealthPlan Yes $0 Yes $0 “personsathighrisk” Yes $0“Personsathighriskfor

infectionoraone‐timescreeningforadultsbornbetween1945and1965“

*OurassessorswereunabletoconfirmcoverageoftheseHBVserviceswithoneMassHealthMCO–NeighborhoodHealthPlan(NHP).ThisshouldnotbeentakentoindicatethatNHPdoesnotcovertheseservices,butsimplythatmultiplecustomerservicerepresentativeswereunabletoadequatelyanswerassessorquestionsregardingcoverage.

1

ATTACHMENTII:HEPATITISBMEDICATIONCOVERAGEDATA

SILVER‐LEVELQUALIFIEDHEALTHPLANS(QHPS)Abbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy;Util.Mgmt.=UtilizationManagementRequirements

IntronA(Interferon

alfa‐2b)

Pegasys(Peginterferonalfa‐

2a)Epivir(lamivudine) Lamivudine Hepsera(Adefovir

dipivoxil) adefovirdipivoxil Baraclude(Entecavir) Entecavir Tyzeka(Telbivudine) Viread(Tenofovir) Vemlidy(Tenofoviralafenamide/TAF)

PlanName Covered(Y/N) Cost Util.

MgmtCovered(Y/N) Cost Util.

MgmtCovered(Y/N) Cost Util









Mgmt

AmbetterBalancedCare

14Yes $90 PA Yes $90 PA Yes $90 PA,

QL Yes $20 PA,QL Yes $90 PA,



QL Yes $60 None No N/A N/A

AccessBlueBasic(BCBSof

MA)Yes $60 PA Yes $60 None Yes $60 None Yes $20 None Yes $90 None Yes $20 None Yes $60 None Yes $20 None No N/A N/A Yes $60 None Yes $60 None

BMCHealthNetPlanSilverA Yes $60 None Yes $60

PA,QL Yes $60 None Yes $20 None Yes* $60 PA Yes $20 None Yes $60 ST Yes $20 None Yes $90 None Yes $60 None Yes $90 PA

BMCHealthNetPlanSilverB

Yes 35% None Yes 35% PA,QL

Yes 35% None Yes $30 None Yes* 35% PA Yes $30 None Yes 35% ST Yes $30 None Yes 35% None Yes 35% None Yes 35% PA

FallonHealthCommunityCareSilverCoinsurance

35%

Yes 50% PA Yes 50% None Yes 50% None Yes $20 None Yes 50% PA Yes $20 PA Yes 50% PA Yes $20 PA Yes 50%PA,QL Yes 50% None Yes* 50% PA

FallonHealthDirectCareSilver

Connector

Yes $90 PA Yes $90 None Yes $90 None Yes $20 None Yes $90 PA Yes $20 PA Yes $90 PA Yes $20 PA Yes $90PA,QL Yes $60 None Yes* $90 PA

FallonHealthSelectCareSilver

Coinsurance35%

Yes 50% PA Yes 50% None Yes 50% None Yes $20 None Yes 50% PA Yes $20 PA Yes 50% PA Yes $20 PA Yes 50% PA,QL Yes 50% None Yes* 50% PA


Connector

Yes $90 PA Yes $90 None Yes $90 None Yes $20 None Yes $90 PA Yes $20 PA Yes $90 PA Yes $20 PA Yes $90 PA,QL

Yes $60 None Yes* $90 PA

StandardSilver(HarvardPilgrim)

Yes $90 None Yes $90 None Yes $60 None Yes $20 None No N/A N/A Yes $20 None Yes $60 None Yes $20 None Yes $90 None Yes $60 None No N/A N/A

CoreCoverageHMO1750(HarvardPilgrim)

Yes 20% None Yes $110 None Yes $80 None Yes $25 None No N/A N/A Yes $25 None Yes $80 None Yes $25 None Yes 20% None Yes $80 None No N/A N/A

HNESilverA Yes $0 None Yes $90 PA,QL

No N/A N/A Yes $20 None No N/A N/A Yes $20 None No N/A N/A Yes $20 None No N/A N/A Yes $60 None No N/A N/A

MyDocHMOSilverBasic(Minuteman)

Yes $0 None Yes $90 PA,QL No N/A N/A Yes $20 None No N/A N/A Yes* $20 None No N/A N/A Yes $20 None No N/A N/A Yes $60 None No N/A N/A

MyDocHMOSilverPlus(Minuteman)

Yes $0 None Yes $50 PA,QL No N/A N/A Yes $13 None No N/A N/A Yes $13 None No N/A N/A Yes $13 None No N/A N/A Yes $30 None No N/A N/A

2

IntronA(Interferon

alfa‐2b)


2a)Epivir(lamivudine) Lamivudine Hepsera(Adefovir













Mgmt

NHPPrimeHMO

2000/400030/5035%FlexRX4‐tier

Yes $0 QL Yes 35%PA,QL Yes 35% QL Yes $30 QL No N/A N/A Yes $30 QL Yes 35% QL Yes $30 QL No N/A N/A Yes 35% QL No N/A N/A

NHPPrimeHMO

2000/400030/50FlexRX

4‐Tier

Yes $0 QL Yes $60 PA,QL Yes $60 QL Yes $20 QL No N/A N/A Yes $20 QL Yes $60 QL Yes $20 QL No N/A N/A Yes $60 QL No N/A N/A

TuftsHealthDirectSilver

2000Yes $60 None Yes $60 QL Yes $60 None Yes $20 None No N/A N/A Yes $20 None Yes $60 None Yes $60 None Yes $60 None Yes $60 None Yes $60 None

TuftsHealthDirectSilver2200withCoinsurance

Yes 50% None Yes 50% QL Yes 50% None Yes $35 None No N/A N/A Yes $35 None Yes 50% None Yes 50% None Yes 50% None Yes 50% None Yes 50% None

TuftsHealthPremierSilver

2000Yes $60 None Yes $60 QL Yes $60 None Yes $20 None No N/A N/A Yes $20 None Yes $60 None Yes $60 None Yes $60 None Yes $60 None Yes $60 None

*Anasteriskindicatesthattheplan’sdrugformularydoesnotlistthesedrugs.However,representativesstatethattheyarecoveredwiththecostandutilizationmanagementrequirementsindicated.

CONNECTORCAREPLANSAbbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy;Util.Mgmt.=UtilizationManagementRequirements

IntronA(Interferon

alfa‐2b)


2a)Epivir(lamivudine) lamivudine Hepsera(Adefovir





MgmtCovered(Y/N) Cost

UtilMgmt

Covered(Y/N) Cost Util.


Util.Mgmt



Util.Mgmt




Mgmt

ConnectorCare1

(Ambetter)Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA,

QL Yes $1 PA,QL Yes $3.65 PA,

QL Yes $3.65 PA Yes $3.65 PA,QL Yes $3.65 PA,

QL Yes $3.65 PA,QL Yes $3.65 None No N/A N/A

ConnectorCare2

(Ambetter)Yes $40 PA Yes $40 PA Yes $40 PA,


QL Yes $40 PA Yes $40 PA,QL Yes $40 PA,

QL Yes $40 PA,QL Yes $20 None No N/A N/A

ConnectorCare3

(Ambetter)Yes $50 PA Yes $50 PA Yes $50 PA,

QLYes $12.50 PA,

QL Yes $50 PA,QL

Yes $50 PA Yes $50 PA,QL

Yes $50 PA,QL

Yes $50 PA,QL

Yes $25 None No N/A N/A

ConnectorCareZero(BMC

HealthNet)

Yes $0 None Yes $0PA,QL Yes $0 None Yes $0 None Yes* $0 PA Yes* $0 None Yes $0 ST Yes $0 None Yes $0 None Yes $0 None Yes $0 PA

ConnectorCareZeroSilver(BMCHealthNet)

Yes $0 None Yes $0 PA,QL

Yes $0 None Yes $0 None Yes* $0 PA Yes* $0 None Yes $0 ST Yes $0 None Yes $0 None Yes $0 None Yes $0 PA

ConnectorCarePlanType

I(BMCHealthNet)

Yes $3.65 None Yes $3.65 PA,QL

Yes $3.65 None Yes $1 None Yes* $3.65 PA Yes* $1 None Yes $3.65 ST Yes $1 None Yes $3.65 None Yes $3.65 None Yes $3.65 PA

3

IntronA(Interferon

alfa‐2b)








UtilMgmt



Util.Mgmt



Util.Mgmt




Mgmt


II(BMCHealthNet)

Yes $20 None Yes $20PA,QL Yes $20 None Yes $10 None Yes* $20 PA Yes* $10 None Yes $20 ST Yes $10 None Yes $40 None Yes $20 None Yes $40 PA


III(BMCHealthNet)

Yes $25 None Yes $25PA,QL Yes $25 None Yes $12.50 None Yes* $25 PA Yes* $12.50 None Yes $25 ST Yes $12.50 None Yes $50 None Yes $25 None Yes $50 PA

CommunityCarePlanTypeI(Fallon)

Yes $3.65 PA Yes $3.65 None Yes $3.65 None Yes $3.65 None Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA,QL Yes $3.65 None Yes* $3.65 PA

CommunityCarePlanTypeII(Fallon)



CommunityCarePlanTypeIII(Fallon)



ConnectorCare1(HNE) Yes $0 None Yes $3.65 PA,

QL No N/A N/A Yes $1 None No N/A N/A Yes $1 None No N/A N/A Yes $1 None No N/A N/A Yes $3.65 None No N/A N/A

ConnectorCare2(HNE)

Yes $0 None Yes $40 PA,QL

No N/A N/A Yes $10 None No N/A N/A Yes $10 None No N/A N/A Yes $10 None No N/A N/A Yes $20 None No N/A N/A

ConnectorCare3(HNE) Yes $0 None Yes $50 PA,

QL No N/A N/A Yes $12.50 None No N/A N/A Yes $12.50 None No N/A N/A Yes $12.50 None No N/A N/A Yes $40 None No N/A N/A

MyDocHMOConnectorCare1(Minuteman)

Yes $0 None Yes $3.65PA,QL No N/A N/A Yes $1 None No N/A N/A Yes* $1 None No N/A N/A Yes $1 None No N/A N/A Yes $3.65 None No N/A N/A


Yes $0 None Yes $40PA,QL No N/A N/A Yes $10 None No N/A N/A Yes* $10 None No N/A N/A Yes $10 None No N/A N/A Yes $20 None No N/A N/A


Yes $0 None Yes $50PA,QL No N/A N/A Yes $12.50 None No N/A N/A Yes* $12.50 None No N/A N/A Yes $12.50 None No N/A N/A Yes $25 None No N/A N/A

NHPPrimeHMO

ConnectorCare0/0

Yes $0 QL Yes $3.65 PA,QL

Yes $3.65 QL Yes $1 QL No N/A N/A Yes $1 QL Yes $3.65 QL Yes $1 QL No N/A N/A Yes $3.65 QL No N/A N/A

NHPPrimeHMO

ConnectorCare10/18

Yes $0 QL Yes $20 PA,QL Yes $20 QL Yes $10 QL No N/A N/A Yes $10 QL Yes $20 QL Yes $10 QL No N/A N/A Yes $20 QL No N/A N/A

NHPPrimeHMO

ConnectorCare15/22

Yes $0 QL Yes $25 PA,QL Yes $25 QL Yes $12.50 QL No N/A N/A Yes $12.50 QL Yes $25 QL Yes $12.50 QL No N/A N/A Yes $25 QL No N/A N/A

DirectConnectorCarePlanTypeI(Tufts)

Yes $3.65 None Yes $3.65 QL Yes $3.65 None Yes $1 None No N/A N/A Yes $1 None Yes $3.65 None Yes $3.65 None Yes $3.65 None Yes $3.65 None No N/A N/A

4

IntronA(Interferon

alfa‐2b)








UtilMgmt



Util.Mgmt



Util.Mgmt




Mgmt

DirectConnectorCarePlanTypeII(Tufts)

Yes $20 None Yes $20 QL Yes $20 None Yes $10 None No N/A N/A Yes $10 None Yes $20 None Yes $20 None Yes $20 None Yes $20 None No N/A N/A

DirectConnectorCarePlanTypeIII(Tufts)

Yes $25 None Yes $25 QL Yes $25 None Yes $12.50 None No N/A N/A Yes $12.50 None Yes $25 None Yes $25 None Yes $25 None Yes $25 None No N/A N/A


MASSHEALTHPLANS

Abbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy;Util.Mgmt.=UtilizationManagementRequirements

IntronA(Interferon

alfa‐2b)



dipivoxil) adefovirdipivoxil Baraclude(Entecavir) entecavir Tyzeka(Telbivudine) Viread(Tenofovir) Vemlidy(Tenofoviralafenamide/TAF)












Mgmt

MassHealthPCCP Yes $3.65 None Yes $3.65 PA Yes $3.65 PA,

QL Yes $3.65 PA,QL Yes $3.65 PA,



QL Yes $3.65 PA,QL Yes $3.65 PA

BMCHealthNet Yes $3.65 None Yes $3.65 PA,QL

Yes $3.65 None Yes $3.65 None Yes $3.65 ST Yes $3.65 None Yes $3.65 ST Yes $3.65 None Yes $3.65 None Yes $3.65 None Yes $3.65 PA

CeltiCareHealthPlan Yes* $3.65 PA Yes* $3.65 PA Yes $3.65 QL Yes $3.65 QL Yes* $3.65 PA Yes* $3.65 PA Yes* $3.65 PA Yes* $3.65 PA Yes* $3.65 PA Yes $3.65 QL Yes* $3.65 PA

FallonHealth Yes $2.00 PA Yes $2.00 None Yes $2.00 None Yes $2.00 None Yes $2.00 PA Yes $2.00 PA Yes $2.00 PA Yes $2.00 PA Yes $2.00 PA,QL

Yes $2.00 None No N/A N/A

HealthNewEngland(HNE) Yes $0 None Yes $3.65

PA,QL No N/A N/A Yes $3.65 None No N/A N/A Yes* $3.65 None No N/A N/A Yes $1 None No N/A N/A Yes $3.65 None No N/A N/A

NeighborhoodHealthPlan(NHP)

Yes $1 QL Yes $3.65 PA,QL

Yes $3.65 None Yes $3.65 None No N/A N/A Yes $3.65 QL Yes $3.65 QL Yes $3.65 QL No N/A N/A Yes $3.65 None No N/A N/A

TuftsHealthPlan Yes $0 None Yes $3.65 QL No N/A N/A Yes $3.65 None No N/A N/A Yes $3.65 None Yes $3.65 None Yes $3.65 None Yes $3.65 None Yes $3.65 None No N/A N/A


1

ATTACHMENTIII:HEPATITISCMEDICATIONCOVERAGEDATA

SILVER‐LEVELQUALIFIEDHEALTHPLANS(QHPS)Abbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy;Util.Mgmt.=UtilizationManagementRequirements

Daklinza(daclatasvir)

Epclusa(sofosbuvir/velpatasvir)

Harvoni(ledipasvir,sofosbuvir) Olysio(simeprevir) Sovaldi(sofosbuvir)

ViekiraPak(ombitasvir,

paritaprevir,ritonavir)

Zepatier(elbasvirandgrazoprevir)


Mgmt.Covered(Y/N) Cost Util.






Mgmt.AmbetterBalanced

Care14 Yes $90 PA,QL Yes $90 PA Yes $90 PA,QL No N/A N/A Yes $90 PA,QL No N/A N/A No N/A N/A

AccessBlueBasic(BCBSofMA) No N/A N/A Yes $60 PA,QL Yes $60 PA,QL No N/A N/A No N/A N/A No N/A N/A No N/A N/A

BMCHealthNetPlanSilverA Yes $90 PA Yes $90 PA Yes $90 PA,QL Yes $90 PA,QL Yes $90 PA,QL Yes $90 PA,QL Yes $90 PA

BMCHealthNetPlanSilverB Yes $90 PA Yes 35% PA Yes 35% PA,QL Yes 35% PA,QL Yes 35% PA,QL Yes 35% PA,QL Yes 35% PA

FallonHealthCommunityCareSilverCoinsurance

35%

Yes $50 PA Yes 50% PA Yes 50% PA Yes 50% PA Yes 50% PA Yes 50% PA Yes 50% PA

FallonHealthDirectCareSilver

ConnectorYes $90 PA Yes $60 PA Yes $60 PA Yes $90 PA Yes $90 PA Yes $90 PA Yes $90 PA

FallonHealthSelectCareSilverCoinsurance35%

No N/A N/A Yes 50% PA Yes 50% PA Yes 50% PA Yes 50% PA Yes 50% PA Yes 50% PA


ConnectorNo N/A N/A Yes $60 PA Yes $60 PA Yes $90 PA Yes $90 PA Yes $90 PA Yes $90 PA

StandardSilver(HarvardPilgrim) No N/A N/A Yes $90 PA,QL Yes $90 PA,QL No N/A N/A Yes $90 PA,QL No N/A N/A Yes $90 PA,QL

CoreCoverageHMO1750

(HarvardPilgrim)No N/A N/A Yes $110 PA,QL Yes $110 PA,QL No N/A N/A Yes $110 PA,QL No N/A N/A Yes $11

0 PA,QL

HNESilverA Yes $90 PA,QL Yes $60 PA,QL Yes $60 PA Yes $90 PA Yes $60 PA Yes $90 PA Yes $90 PA,QLMyDocHMOSilverBasic(Minuteman) Yes $110 PA,QL Yes $60 PA,QL Yes $60 PA Yes $90 PA Yes $60 PA Yes $90 PA Yes $90 PA,QL

2














Mgmt.MyDocHMOSilverPlus(Minuteman) Yes $90 PA Yes $30 PA,QL Yes $30 PA Yes $50 PA Yes $30 PA Yes $50 PA Yes $50 PA,QL

NHPPrimeHMO2000/400030/5035%FlexRX4‐tier

Yes $90 PA Yes 35% PA Yes 35% PA Yes* 35% PA Yes* 35% PA Yes* 35% PA Yes* 35% PA

NHPPrimeHMO2000/400030/50FlexRX4‐Tier

Yes $50 PA Yes $60 PA Yes $60 PA Yes* $90 PA Yes* $90 PA Yes* $90 PA Yes* $90 PA

TuftsHealthDirectSilver2000 No N/A N/A No N/A N/A No N/A N/A No N/A N/A Yes $90 PA Yes $60 PA No N/A N/A

TuftsHealthDirectSilver2200withCoinsurance

No N/A N/A No N/A N/A No N/A N/A No N/A N/A Yes 50% PA Yes 50% PA No N/A N/A

TuftsHealthPremierSilver

2000No N/A N/A Yes $90 PA No N/A N/A No N/A N/A Yes $90 PA Yes $60 PA No N/A N/A


CONNECTORCAREPLANSAbbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy;Util.Mgmt.=UtilizationManagementRequirements














Mgmt.ConnectorCare1(Ambetter) Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA,QL No N/A N/A Yes $3.65 PA,QL No N/A N/A No N/A N/A

ConnectorCare2(Ambetter) Yes $40 PA Yes $40 PA Yes $40 PA,QL No N/A N/A Yes $40 PA,QL No N/A N/A No N/A N/A

ConnectorCare3(Ambetter) Yes $50 PA Yes $50 PA Yes $50 PA,QL No N/A N/A Yes $50 PA,QL No N/A N/A No N/A N/A

ConnectorCareZero(BMCHealthNet)

Yes $0 PA,QL Yes $0 PA Yes $0 PA,QL Yes $0 PA,QL Yes $0 PA,QL Yes $0 PA,QL Yes $0 PA

3














Mgmt.ConnectorCareZeroSilver(BMCHealthNet)


ConnectorCarePlanTypeI(BMCHealthNet)

Yes $3.65 PA,QL Yes $3.65 PA Yes $3.65 PA,QL Yes $3.65 PA,QL Yes $3.65 PA,QL Yes $3.65 PA,QL Yes $3.65 PA

ConnectorCarePlanTypeII(BMCHealthNet)


ConnectorCarePlanTypeIII(BMCHealthNet)


CommunityCarePlanTypeI(Fallon)

Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA

CommunityCarePlanTypeII(Fallon)

Yes $40 PA Yes $40 PA Yes $40 PA Yes $40 PA Yes $40 PA Yes $40 PA Yes $40 PA

CommunityCarePlanTypeIII(Fallon)

Yes $50 PA Yes $50 PA Yes $50 PA Yes $50 PA Yes $50 PA Yes $50 PA Yes $50 PA

ConnectorCare1(HNE) Yes $3.65 PA Yes $3.65 PA,QL Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA,QL

ConnectorCare2(HNE) Yes $40 PA Yes $20 PA,QL Yes $20 PA Yes $40 PA Yes $20 PA Yes $40 PA Yes $40 PA,QL

ConnectorCare3(HNE) Yes $50 PA Yes $25 PA,QL Yes $25 PA Yes $50 PA Yes $25 PA Yes $50 PA Yes $50 PA,QL


Yes $3.65 PA Yes $3.65 PA,QL Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA,QL


Yes $40 PA Yes $20 PA,QL Yes $20 PA Yes $40 PA Yes $20 PA Yes $40 PA Yes $40 PA,QL


Yes $50 PA Yes $25 PA,QL Yes $25 PA Yes $50 PA Yes $25 PA Yes $50 PA Yes $50 PA,QL


No N/A N/A Yes $3.65 PA Yes $3.65 PA Yes* $3.65 PA Yes* $3.65 PA Yes* $3.65 PA Yes* $3.65 PA

4














Mgmt.NHPPrimeHMOConnectorCare10/18

No N/A N/A Yes $20 PA Yes $20 PA Yes* $40 PA Yes* $40 PA Yes* $40 PA Yes* $40 PA


No N/A N/A Yes $25 PA Yes $25 PA Yes* $50 PA Yes* $50 PA Yes* $50 PA Yes* $50 PA

DirectConnectorCarePlanTypeI(Tufts)

No N/A N/A No N/A N/A No N/A N/A No N/A N/A Yes $3.65 PA Yes $3.65 PA No N/A N/A

DirectConnectorCarePlanTypeII(Tufts)

No N/A N/A No N/A N/A No N/A N/A No N/A N/A Yes $40 PA Yes $20 PA No N/A N/A

DirectConnectorCarePlanTypeIII(Tufts)

No N/A N/A No N/A N/A No N/A N/A No N/A N/A Yes $50 PA Yes $25 PA No N/A N/A


MASSHEALTHPLANSAbbreviations:Cost=PatientCost‐Sharing;PA=PriorAuthorization;QL=QuantityLimit;ST=StepTherapy;Util.Mgmt.=UtilizationManagementRequirements







Insurer Covered(Y/N) Cost Util.







Mgmt.MassHealthPCCP Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA,ST Yes $3.65 PA Yes $3.65 PA,ST Yes $3.65 PA,STBMCHealthNet Yes $3.65 PA,QL Yes $3.65 PA Yes $3.65 PA,QL Yes $3.65 PA,QL Yes $3.65 PA,QL Yes $3.65 PA,QL Yes $3.65 PACeltiCareHealth

Plan Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA No N/A N/A Yes $3.65 PA No N/A N/A Yes $3.65 PA

FallonHealth Yes $2.00 PA Yes $2.00 PA Yes $2.00 PA Yes $2.00 PA Yes $2.00 PA Yes $2.00 PA Yes $2.00 PAHealthNew

England(HNE) Yes $3.65 PA Yes $3.65 PA,QL Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA Yes $3.65 PA,QL

NeighborhoodHealthPlan(NHP) Yes $3.65 PA,QL Yes $3.65 PA,QL Yes $3.65 PA,QL No N/A N/A Yes $3.65 PA,QL No N/A N/A No N/A N/A

TuftsHealthPlan Yes $3.65 PA,QL Yes $3.65 PA Yes $3.65 PA,QL No N/A N/A Yes $3.65 PA,QL Yes $3.65 PA No N/A N/A*Anasteriskindicatesthattheplan’sdrugformularydoesnotlistthesedrugs.However,representativesstatethattheyarecoveredwiththecostandutilizationmanagementrequirementsindicated.

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