Insurance companies are denying members coverage to expensive drugs, like Harvoni, and those infected with HCV are filing lawsuits.
When it comes to hepatitis C virus (HCV), a virus that infects over 160 million individuals worldwide, treatment is crucial in order to prevent a number of severe liver complications that can potentially result in death. Although there are now new HCV drugs available, they can be incredibly costly, and for that reason, a number of insurance companies have denied patients access to these drugs unless they have severe liver damage already.
For those who were unlucky enough to be denied these drugs, they have had to then go through a long appeals process. If they were denied again, the only option that these patients had was to wait until their illness grows worse. This means that insurance companies were essentially forcing patients to develop more serious, maybe even life-threatening symptoms before they are able to access treatment. Needless to say, many individuals felt that these decisions were unfair and they have been waging serious legal battles. Fortunately, some of these efforts have resulted in some big wins.
One such instance happened in California, where a class action lawsuit against Blue Shield Life & Health and Blue Shield of California was filed back in October 2015 by Aram Homampour, John Bartels, and Jon Naka, all HCV-positive individuals. According to a recent press release, all three of these individuals had been denied coverage that would allow them access to Harvoni, a popular medicine that is used to treat chronic HCV. They were denied “on the grounds that the drug was not medically necessary because the patients’ liver damage was not severe enough.”
In fact, upon closer inspection of the policies of Blue Shield of California, advanced liver damage is necessary in order to qualify for coverage that includes Harvoni. The only other way to qualify for the drug is to “show a contraindication” to Abbvie’s Viekira Pak, a drug that proves to be less costly ($84,000 for full-course treatment), than Harvoni (which costs $99,000 for full-course treatment) but has been known to cause a number of serious adverse side effects.
In their defense, the plaintiffs argued that these denials were in direct violation of the Employee Retirement Income Security Act of 1974 (ERISA), which “is a federal law that sets minimum standards for most voluntary established pension and health plans in private industry to provide protection for individuals in these plans.”
The efforts of the plaintiffs were rewarded when Blue Shield of California updated its policies at the end of 2015 to expand coverage, allowing members with less severe liver damage to also access Harvoni to use as a part of their treatment regimens. Furthermore, they also eliminated the contraindication requirement a few months after they updated their policies.
These changes are a big win for not only the plaintiffs, but all HCV-positive members who seek to obtain safe and effective treatment for their illness. In fact, the insurance company sent out letters in April and May to members who had been denied coverage of Harvoni in the past and implored them to resubmit their requests for coverage.
Due to the fact that Blue Shield of California expanded their coverage, US District judge, William H. Orrick, has dismissed the class action lawsuit. According to the press release, the court opinion stated, “Given these actions, recurrence of the challenged practice is unlikely and plaintiffs’ claims against Blue Shield of California for denial of benefits are moot.”
Furthermore, the court opinion shared that two of the plaintiffs took the drug offered by AbbVie and were “no longer suffering from hepatitis C” and the other one was granted coverage for Harvoni.
This lawsuit is one of many when it comes to insurance companies denying coverage to costly drugs, but fear of being involved in ongoing legal battles have led to a number of restrictions being lifted, allowing more patients access to effective, albeit expensive, HCV drugs that could potentially save their lives.