Notice of Settlement with Group Health/Group Health Options (now known as Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options)Over Access to Drugs to Treat Hepatitis C

There are new, highly effective drugs to treat and cure Hepatitis C.  These drugs are called direct acting anti-virals (DDAs), and include such drugs as Harvoni (ledipasvir-sofosburvir), Olysio (simeprevir), Sovaldi (sofosbuvir), Viekira Pak (ombitasvir/paritaprevir/ritonavir plus dasabuvir) and Zepatier (elbasvir/grazoprevir).  Other similar drugs are in various stages of review and are likely to be approved by the FDA as wel.  If you are insured by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options (formerly known as Group Health and Group Health Options), you may now have the right to seek treatment with these new drugs.

What is this Case About?

A person insured by Group Health brought this lawsuit because Group Health was stopping some people from getting coverage for Harvoni/ledipasvir-sofosbuvir to treat Hepatitis C. He said that Group Health was using a person’s fibrosis score to decide whether to cover the treatment. A person’s fibrosis score tells how much Hepatitis C has scarred the person’s liver. A higher score means more scarring.

After the case was filed, Group Health stopped using fibrosis scores to decide who could get the new Hepatitis C drugs.  Given this change in coverage policy, the parties then talked with each other to see if the case could be settled. Those talks resulted in an agreement to settle the case.  The judge preliminarily approved the settlement on April 14, 2017. You can seek coverage now.

Group Health and Group Health Options are now known as Kaiser Foundation Health Plan of Washington and Kaiser Foundation Heath Plan of Washington Options ("KFHPW").

More detail can be found in the motion for approval, which is here.

A copy of the class notice is attached here.

Class counsel's motion for approval of fees, costs and an incentive award can be found here.

Am I a Member of the Class?

The class is defined as someone who:

(i)                have been, are, or will be insured under a“health plan,” as that term is defined by RCW 48.43.005(26), which is not subject to the Employee Retirement Income Security Act, 29 U.S.C. §1001 et seq., on or after October 10, 2014, by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Heath Plan of Washington Options ["KFHPW"]; and

(ii)       have received, require, or are expected to require treatment for Hepatitis C with Harvoni/ledipasvir-sofosbuvir or other similar FDA-approved direct acting antiviral under the current guidelines adopted by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (see http://www.hcvguidelines.org/full-report/when-and-whom-initiate-hcv-therapy); and

(iii)     did not meet the coverage criteria for HCV medication applied by KFHPW in its pre-March 4, 2016 coverage policy because  the individual’s fibrosis score was not high enough under KFHPW's coverage criteria

What Does the Agreement Say?

You can see the whole Agreement here.  Here are the main parts of the Agreement:

Coverage of Harvoni and other similar drugs for the treatment of Hepatitis C

The Agreement says KFHPW shall not re-impose a blanket exclusion on coverage for insureds with HCV based on severity of fibrosis score, unless national medical standards change in the future.

Damage Claims Not Covered by the Settlement Agreement

The Agreement does not cover any claims you may have for a prior denial of Harvoni or another DAA.  Those claims are not released by the Settlement Agreement.  If you believe you have such claims, you will need to pursue them on your own with your own attorney.  The Settlement Agreement only addresses, and releases, claims relating to current and future coverage where fibrosis scores is used to limit coverage.

Attorney’s Fees, Litigation Costs, and Costs of Claims Administration

Under the Settlement Agreement, KFHPW will pay the attorneys’ fees of the attorneys representing the class. This amount will be based upon the attorneys’ normal hourly rates and the time they spent on the case, and will not exceed $36,160.50.  In addition, KFHPW will pay the attorneys the money they paid out of pocket on behalf of the class, up to $361.49.

Case Contribution Award

The judge will be asked to award $2,500 to the class representative as a case contribution award. KFHPW is responsible for paying this sum.  

What is the Timeline?

The Court has established the following deadlines in this Order:

Final Approval Hearing:  July 14, 2017 at 9:00 am, King County Courthouse, Room W-905

All comments and objections from class members due:  June 30, 2017

Notice to appear at the final hearing due:  June 30, 2017