Suit Claims Anthem's Specialty Pharmacy Policy is Discriminatory

The class action lawsuit against Anthem Blue Cross alleges their policy mandating that patients use a mail-order specialty pharmacy discriminates against HIV patients.

Anthem Blue Cross’ new proposed pharmacy policy requires that all patients seeking to fill their specialty medications do so through a mail-order pharmacy approved by the insurer (CuraScript). This new change in policy, one that the insurer says will be put into place on March 1, 2013, as a cost-saving measure, is a discriminatory practice, according to both the California attorney general’s office and the advocacy group Consumer Watchdog.

Consumer Watchdog filed a statewide class action suit against the health plan, alleging that the pharmacy program unfairly discriminates against people who have been prescribed HIV/AIDS-related maintenance medications. The advocacy group contends Anthem’s conduct is a violation of the Unruh Civil Rights Act, which outlaws discrimination based on “sex, race, color, religion, ancestry, national origin, disability, medical condition, genetic information, marital status, or sexual orientation.”

Consumer Watchdog noted in the suit that under Anthem’s new rules, “using a retail pharmacy will be considered going ‘out-of-network’ for these seriously ill consumers who will be required to pay full price for their specialty medicines, many costing several thousand dollars each month.”

According to The California Report blog, Anthem issued a statement defending their new program that stated, “This program allows our contracted specialty pharmacy to secure bulk discounts for high cost drugs that help keep the benefit more affordable.” Anthem also argued that their mail-order pharmacy has HIV support programs that, from their research, produced an adherence rate that was 10% higher than for those patients using a retail pharmacy. Additionally, Anthem denied that the policy change was discriminatory, saying that the policy applies not just to HIV patients, but to all patients using specialty pharmaceuticals, including those with cancer and multiple sclerosis.

Marta Green of the California Department of Managed Health Care said that there are already 3 similar specialty pharmacy initiatives in place in the state of California: Health Net, Sharp, and United Health Care of California. But she also told the LA Times that Anthem failed to communicate to their policyholders that patients “for whom a mail-order pharmacy may not be appropriate” could request a hardship waiver to opt out of the program. Other plans, like Humana, sometimes require their members to use a mail-order pharmacy for specialty medications — but Marina Renneke, a Humana spokesperson, told the LA Times that these types of requirements in their plans are determined by the employer offering the health plan, and not by the health plan itself.

David Balto, JD, who has allegedly been retained by retail drugstores to challenge Anthem’s mandate, wrote in a Huffington Post blog post in December 2012 that HIV patients rely on community specialty pharmacies for their life-saving medications—especially when there are problems with mail-order pharmacy shipments. He said that patients lose when they are forced into mail-order situations, and that specialty pharmacists “provide a full slate of advising and counseling services to help patients and their families navigate the challenges of living with a chronic and often debilitating condition. Many specialty pharmacies also have programs to help low-income patients afford their ever rising co-pays.”

For a patient perspective on these new policies, please read “Specialty Pharmacies Unscripted” by Larry Kramer on POZ.