Gilead Sciences' Sovaldi was approved in December by the FDA and has been shown to have cure rates higher than 80%. As many as 3.2 million people have the disease, and 20% to 35% of them are estimated to be enrolled in Medicaid, according to the trade group for the managed-care plans, which would make at least 600,000 beneficiaries candidates for the drug.
Gilead reported this month that U.S. sales of the drug reached $2.1 billion in the first quarter of 2014, and 7%, or $160 million, came from state Medicaid programs. Myers estimated that Sovaldi could cost state Medicaid programs as much as $1.5 billion a year and noted that if costs for other current and emerging hepatitis C drugs are added, spending on drugs for this one disease could top $2 billion annually. Johnson & Johnson's Olysio costs $66,000 for 12 weeks of treatment, and Gilead is expected to release another offering in October.
“We need to look at how to best provide treatment so that we don't destabilize the program,” Myers said.
Thirty-seven states and Washington, D.C., contract with Medicaid managed-care plans, which are not eligible for the 23.1% discount that state Medicaid programs get for branded drugs under the Patient Protection and Affordable Care Act. Even states with traditional fee-for-service programs would recoup only about $230 a pill—the course of treatment would still cost nearly $65,000.
Molina Healthcare offers health plans in California, Florida, Illinois, Michigan, New Mexico, Ohio, South Carolina, Texas, Utah, Washington and Wisconsin. None of these states currently reimburses the company for the Sovaldi, so Molina has created guidelines that limit coverage of the drug to the neediest cases, in most cases meaning the patient has developed cirrhosis, the final stage of chronic liver disease.
Dr. J. Mario Molina, the company's president and CEO, said he hopes creating a work group with state officials could lead to discussions about other costly drugs that may be in the pipeline. “These new drugs could be a budget buster for state Medicaid programs,” Molina said.
Some experts are downplaying Sovaldi's effect on Medicaid programs and insurers. “The problem should become less acute in future years as Sovaldi competitors reach the market, price competition increases and the backlog of patients with long-standing infections begins to clear,” said David Williams, president of Boston-based consulting firm Health Business Group.
In the meantime, it could take years for the full population of candidates for Sovaldi to find their way to the drug because many don't know they have the disease, said Alan Weil, executive director of the National Academy for State Health Policy. “So there is time to build this into future rates.”