A West Hollywood woman sued insurer Anthem Blue Cross for refusing to cover the cost of an expensive drug that she says would cure her hepatitis C infection.
Shima Andre said in the lawsuit that Anthem has refused to pay the estimated $99,000 it would cost to be treated with the controversial drug Harvoni, which has been shown to destroy the 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, said she was thrilled when the Food and Drug Administration approved the drug last year. But she hasn't been able to take it because Anthem declined to cover the cost. She said she has postponed becoming pregnant because she fears she would pass along the virus to her child.
It's unconscionable, Andre said, that Anthem won't pay for the drug, which is manufactured by Gilead Sciences Inc. of Foster City, near San Francisco.
“I can't believe that they demand that a person get sicker before they'll pay for a cure,” she said. “If there's a cure for something and you have health insurance, they should cover it.”
Anthem Blue Cross spokesman Darrel Ng declined to comment.
Anthem denied coverage despite the recommendation of Andre's doctor, who has unsuccessfully lobbied the insurer to cover the drug, said her lawyer, Ricardo Echeverria.
“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.
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 suit.
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 has faced criticism over the high price of Harvoni and Sovaldi, another of its drugs that is highly effective at treating hepatitis C. In December, Philadelphia's transit agency sued the 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.”
Hepatitis C is a virus, spread through contact with blood, that attacks the liver. The disease is potentially deadly, but people can live with it for years.