May 18--A West Hollywood woman sued Anthem Blue Cross for refusing to pay for an expensive but effective drug she says would cure her hepatitis C infection.
Shima Andre said in the lawsuit that Anthem has refused to pay the $99,000 it would cost to be treated with the controversial drug Harvoni, which has been proved to wipe out the potentially deadly virus in most patients.
In a denial letter, Anthem explained that the drug was "not medically necessary" because Andre does not have advanced liver damage, the lawsuit said.
"We may approve Harvoni when the liver has a certain amount of scarring on a liver biopsy," the insurer explained. "Records we received do not show that your liver has this amount of scarring."
Andre, 42, who was diagnosed with hepatitis C in 2011, wants to wipe out the disease before it causes permanent damage, said her attorney, Ricardo Echeverria. She also has postponed becoming pregnant because she fears she would pass along the virus to her child, he said.
Anthem denied coverage despite the recommendation of her doctor, who has unsuccessfully lobbied the insurer to cover the drug, her lawyer said.
"How can it not be medically necessary when your treating doctor recommends it, it's the standard of care and it will cure the disease?" Echeverria said.
Anthem Blue Cross spokesman Darrel Ng declined to comment.
The lawsuit, filed Friday in Los Angeles County Superior Court, accuses Anthem of breach of contract, infliction of emotional distress and unfair business practices. It seeks certification as a class action lawsuit, which would add others denied the drug to the lawsuit.
The Food and Drug Administration approved Harvoni in October. Harvoni is a pill taken once a day for eight to 12 weeks that has been proved in clinical testing to wipe out the virus in more than 90% of patients, without significant side effects.
Gilead Sciences Inc. has faced criticism over the high price of Harvoni and Sovaldi, another drug that is highly effective at treating hepatitis C. In December, Philadelphia's transit agency sued the Foster City, Calif., company, saying its pricing of Sovaldi amounted to "price gouging."
Echeverria said the cost of the drug should not prevent Andre from receiving coverage.
"That's an issue for the insurers and the pharmaceutical companies to work out a price that works for them," the attorney said. "But don't let the patients hang in the balance."
