Eric Schneiderman for Attorney General

AG settles with CDPHP over hepatitis C coverage

May 27, 2016

As published in the Times Union on May 18, 2016.

ALBANY — The state Attorney General has reached an agreement with CDPHP over its coverage of hepatitis C treatments, ending a lawsuit filed last month that accused the Albany-based health insurer of breaking the law by delaying coverage until patients were in advanced stages of the disease.

Under the terms of the agreement, Capital District Physicians’ Health Plan will no longer restrict coverage of some hepatitis C treatments to only those patients with severe symptoms, such as scarred livers. The insurer also agreed to cease denying coverage based on patients’ alcohol or drug use and to allow treatment authorized by any appropriately trained provider, not just liver specialists.

The insurer will also pay $25,000 in legal fees and must provide notice of the policy changes to existing members who previously were denied coverage for treatment of the liver disease.

The agreement comes on the heels of settlements reached by Attorney General Eric Schneiderman’s office with seven other private insurers, including Schenectady-based MVP Health Care and the parent of Latham-based BlueShield of Northeastern New York, following an investigation that determined they were inappropriately delaying or otherwise restricting coverage for hepatitis C treatment.”With today’s settlement, my office has now reached agreements with every private health insurance plan in New York that was previously denying certain forms of coverage for Hepatitis C,” Schneiderman said. “This is a victory for public health and for patients across the state.”

A spokeswoman for the Albany-based insurer confirmed the agreement but declined further comment.

Terms of settlements with the seven other insurance companies were similar to the one reached with CDPHP. The Albany-based insurer, however, is the only one that must reimburse the attorney general for costs associated with its investigation.

The attorney general’s office filed a lawsuit in mid-April contending CDPHP failed to cover medically necessary care and deceived members about their coverage. According to that suit, CDPHP members diagnosed with early-stage chronic hepatitis C infection were required to monitor their illness and wait until they developed advanced symptoms before treatment was covered.

Schneiderman found other insurers guilty of the same practices, but reached settlements with them rather than suing. Agreements with the seven other insurers were announced about 10 days after the Attorney General filed the suit against CDPHP. Shortly afterward, the state’s Medicaid program also changed its policies to cover treatments for patients in earlier stages of the disease.

CDPHP has previously suggested the Attorney General singled out the insurer for political purposes. Schneiderman’s office refused its request to participate in talks that led to agreements with other insurers, CDPHP said in a previous statement.

Hepatitis C is a blood-borne virus that can cause chronic infection of the liver and, in the worst cases, liver failure and death. An estimated 25,000 new cases occur each year in New York.

People at risk for the condition include injection drug users and anyone who had a blood transfusion before 1992. Baby boomers are five times more likely than others to have the illness, according to federal data.

Several new drugs have become available in recent years for treatment of hepatitis C. Federal approval in 2014 of Harvoni, made by Gilead Sciences, was hailed for two reasons: It provides a complete cure for most patients who take it, and it comes in a once-a-day pill form that does not have to be taken in combination with drugs that cause severe side effects.

But the list price for a complete course of Harvoni tops $90,000. Insurance companies typically negotiate discounts for the drugs.

The drug’s cost is often cited in calls to reform pharmaceutical company practices that lead to exorbitant pricing.