• Companies include Empire BlueCross, Excellus Health, Affinity
  • Seven companies agree in negotiations with attorney general

Seven insurers including Anthem Inc. and Affinity Health Plan reached an agreement with New York Attorney General Eric Schneiderman to cover hepatitis C drugs for patients in the early stages of the disease and for drug and alcohol users.

Five of the insurers have covered only patients who also had liver scarring or other serious effects of the disease, according to a statement Tuesday by Schneiderman. Four have denied coverage to alcohol and drug users even though dirty needles are a main mode of transmission.

New treatments for the disease are highly effective and can cost as much as $94,500 before discounts, according to court documents. Some insurers have denied coverage to those in the early stages of the disease on the basis that treatment is not “medically necessary” until they have more advanced liver scarring. 

In a lawsuit against an insurer not a part of Tuesday’s deal, Schneiderman said these denials were motivated by cost considerations rather than medical advice. Five of the seven insurers in Tuesday’s agreement had similar policies in place and have now agreed to cover the drugs for patients in early stages of the disease.

“New Yorkers diagnosed with hepatitis C deserve to be treated, and these agreements will vastly improve access to the medications needed to cure their disease,” Schneiderman said in the statement. “My office will do everything possible to ensure treatment for hepatitis C is available, so that patients can be cured and we can minimize the spread of the disease to others.”

Companies Covered

The agreement announced Tuesday was the result of an earlier probe into health insurers’ hepatitis C coverage in the state. The agreement was reached with Affinity Health Plan, Anthem’s Empire BlueCross BlueShield, Excellus Health Plan, HealthNow, Independent Health, United Healthcare/Oxford and MVP Health Plan, the attorney general said.

Melissa Golen, a spokeswoman for HealthNow, said the company “has cooperated fully” with the state and has modified policies in light of new research. An MVP spokeswoman, Jo Ann LeSage Nelson, said the agreement is consistent with “principles and practices already in place” at the company.

A spokeswoman for Excellus, Liz Martin, said in a statement that the company is “voluntarily changing our policy in a manner that reflects consistent and emerging treatment guidelines for chronic hepatitis C.”

An Anthem spokeswoman, Jill Becher, said in a statement that the company’s New York affiliate, Empire Blue Cross BlueShield, also voluntarily entered into the agreement “to establish uniform criteria in the evolving area of treatment for hepatitis C.”

Pre-Agreement Action

The insurer “began proactively modifying its criteria relating to hepatitis C treatments prior to this agreement, in January of this year,” Becher said.

Affinity Health Plan "has agreed to slightly revise" eligibility criteria for its commercial line of business and expects "very few members to be impacted by this change" because it represents only about 7 percent of its policyholders, the company’s Chief Medical Officer Sharon Deans said in a statement. Affinity primarily offers state-sponsored coverage in New York for people eligible for Medicaid or without other health insurance.

Representatives from UnitedHealth and Independent Health didn’t immediately respond to requests for comment on the agreement.

The settlement came after Schneiderman asked insurers for information about their coverage of hepatitis C treatments amid concerns that some were denying or limiting coverage of the expensive medications. The state official issued subpoenas to as many as 16 insurers requesting documents explaining how they make decisions on who to cover or not, a person familiar with the matter told Bloomberg in March.

State’s Lawsuit

Schneiderman sued Capital District Physician’s Health Plan Inc. earlier this month, accusing the insurer of denying almost half the hepatitis C claims it received in 2014 and 2015 “for treatment with one of the most effective medications available.”

After the probe was begun, Capital District Physician’s Health Plan “made it clear that CDPHP was willing to work with his office and our principal regulators,” Robert Hinckley, the chief strategy officer, said in a statement. “The AG opened discussions with other health plans to negotiate their proposed policy changes. CDPHP expressed a willingness to join that agreement; however the AG refused to allow our participation.”

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