Dive Brief:
- A California woman has filed suit against Anthem Blue Cross for refusing to cover the estimated $99,000 it would cost to treat, and likely cure, her Hepatitis C with the drug Harvoni.
- The woman is accusing Anthem of breach of contract, infliction of emotional distress and unfair business practices, and seeks certification as a class-action lawsuit.
- Others are also calling out insurers and pharmaceutical companies over the so-called "rationing of treatment" due to high drug prices, calling the restrictions discrimminatory.
Dive Insight:
The issue puts insurers in a tight place as a result of the negative publicity and the questions surrounding the legality of such denials.
In the California woman's case, Anthem denied the drug because she did not yet have advanced liver damage. She calls the postponement until she gets sicker "unconscionable" and notes that in the meantime she has had to forgo getting pregnant to avoid passing the disease on to her child. She is 42.
Anthem is not alone in its position. Brian R. Edlin, MD, of Weill Medical College of Cornell University told Healio that many halth insurers, both public and private, are requiring advanced fibrosis; cirrhosis; abstinence from alcohol, marijuana and illicit drugs; mandatory drug and alcohol testing; active participation in treatment for substance use; no substance use treatment in the past 12 months; no substance use diagnosis in the past 12 months; no malignancy of any organ; and extensive experience treating HCV by the prescriber. He added that it's also typical to see arduous prior authorization processes.
Edlin argues that such restrictions are discriminatory, lack medical justification and are likely illegal. Perhaps the California case will help to answer that question.