Kentucky

Liver damage restrictions

Fee-For-Service (FFS) does not impose minimum liver damage restrictions. One Managed Care Organization (MCO), Anthem BlueCross BlueShield of Kentucky, requires severe liver damage (F3 or greater). One MCO, Passport Health Plan, requires at least moderate liver damage (F2 or greater). One MCO, CareSource, imposes severe (F3) and moderate (F2) liver damage requirements on two medications, but does not impose minimum liver damage restrictions on most prescriptions. One MCO, Aetna, follows FFS and does not impose any minimum liver damage restrictions. One MCO, WellCare, has unclear liver damage criteria.

Sobriety restrictions

FFS inquires about patients’ past history of substance use, but does not impose mandated periods of abstinence for individuals seeking first-time treatment. One MCO, Anthem, does not list any sobriety requirements. Three MCOs, Aetna, Passport, and WellCare, require screening for current abuse and counseling as to the risks of substance use during treatment. One MCO, CareSource, requires that members are not currently participating in alcohol abuse or illicit substance abuse, evidenced by one confirmed negative urine drug and alcohol screen within the last 60 days; for previous abusers, it requires confirmation of current monthly negative urine drug and alcohol screen for 3 consecutive months.

Prescriber restrictions

FFS requires a prescription to be written by or in consultation with a specialist. Three MCOs, Aetna Better Health, CareSource-Humana and WellCare, require a specialist to prescribe. One MCO, Passport Health Plan, requires a prescription to be written by or in consultation with a specialist. One MCO, Anthem BlueCross BlueShield, does not specify prescriber requirements.

Recommendations

• Eliminate prescriber requirements.
• Ensure and parity across FFS and MCO programs and transparency regarding hepatitis C coverage criteria.