The Health Care Authority on Monday reached a settlement agreement in a class action lawsuit that sought broader coverage of costly hepatitis C drugs for Medicaid patients in Washington state.
The settlement has yet to be approved by a judge but lawyers are hopeful it will be soon.
In the past several years, multiple pharmaceutical companies nationwide have developed direct-acting antiviral drugs that cure hepatitis C in more than 90 percent of patients. But the drugs are extremely expensive - for example, Harvoni, introduced in 2014, has a list price of $1,100 a day, or $94,500 for a 12-week course. (After automatic drug rebates and other discounts, Medicaid pays about half that price for each patient.)
But under the state’s previous restrictions, Medicaid patients with hepatitis C could only access the expensive curative drugs if they had advanced liver disease, gauged by a “fibrosis” score, which measures the level of scarring on the liver.
A class suit representing about 28,000 Medicaid patients was filed against the Health Care Authority in February, alleging that 900 people in the state had been denied access to curative treatment based on their fibrosis score. A preliminary injunction was issued in May, barring the state from denying coverage based on fibrosis score. If approved, the settlement agreement would make that change permanent, opening access to medically necessary treatment to all hep C patients covered by Medicaid.
“The state agreed to remove the fibrosis scores as ... a means of rationing who got access to the drugs,” said attorney Amy Crewdson with Columbia Legal Services, which filed the lawsuit along with Seattle law firm Sirianni Youtz Spoonemore Hamburger. For sick patients seeking a cure, “Fibrosis scores were the big barrier.”
The legal team filed the settlement agreement on Monday and is now awaiting a judge’s preliminary approval to the proposed order. After that’s granted, the judge has to schedule a “fairness hearing” where final approval or denial of the settlement will be determined. The hearing will be sometime in 2017.
Once preliminary approval is given and a date set for the fairness hearing, the state must send out notification to all members of the class suit alerting them to the hearing if they wish to go and submit comments or testify in person.
That notification element is a big benefit of the settlement, lawyers say, because it requires the state to inform Medicaid clients who are eligible for the costly treatment and may have even been denied treatment in the past.
Crewdson says the state has to notify three groups of people, with notices written by the legal team that brought the suit - one for people who are still on Medicaid but were denied expensive hep C treatment in the past; one for people the state believes to no longer be enrolled in Medicaid but who were denied hep C treatment by the agency in the past; and one for people who are currently on Medicaid whom the state has reason to believe could be hep C-positive.
The terms reached in the settlement — ceasing to deny hep C treatment based on fibrosis score — are only effective for three years because the Health Care Authority wanted an expiration date, Crewdson said.
Hopefully, after three years, the increased access will be sufficiently entrenched and will remain in place long-term.
“If (the agency) reverted to their policy of rationing in three years, it’s likely we would just sue them again,” Crewdson said.