Anthem Won’t Cover Name Brands, Suit Says

SAN FRANCISCO (CN) — Anthem Blue Cross refuses to cover name-brand medication, even when there is no equivalent generic or the generic is ineffective, a subscriber claims in a federal class action.

K. F. Petty says in her 16-page complaint against Anthem and Blue Cross of California that in 2007, she was a graduate student and enrolled in Anthem's student plan. She was treated for a medical condition requiring medication — listed in the complaint as "Drug X" to protect her privacy — which had no generic equivalent at the time.

Petty says that a few months later and without notifying her, Anthem changed her prescription to a substitute generic medication which contained the same active ingredient as the brand name she had been taking. Her pharmacy was notified of the change, and the next time she filled her prescription she was given the substitute medication instead.

The problem, Petty says, is that "none of these substitutes were pharmaceutically the same or therapeutically as effective" for her condition.

On subsequent prescriptions, Petty's doctor specified that she should receive the name-brand Drug X rather than the equivalent generic and wrote a letter to Anthem "outlining the medical necessity of Drug X." Anthem continued to refuse to cover the cost of the name-brand medication, Petty says in her complaint.

Throughout her coverage with Anthem, Petty says she had to choose between paying full price for the brand medication or taking the less effective generic substitute covered by Anthem.

Petty represents a class of Anthem clients who have had "to use non-equivalent and/or generic drugs even when the original prescribed drugs are different and medically necessary for proper treatment," according to the complaint.

She says that "Anthem's contracts contain language that it uses to exclude coverage, (i.e., 'brand-name drugs unless a generic equivalent does not exist or if your physician requests no substitutions'), members of the class and California subclass are entitled to coverage for 'brand-name drugs' (such as Drug X) since no generic equivalent exists for these medications and/or their physicians have requested that there be no substitutions for the drugs prescribed."

Anthem's practice of "using an undisclosed criteria at variance with the Evidence of Coverage" violates California law and has caused harm to Petty and thousands of other Californians, according to the complaint.

Petty is suing for breach of implied duty of good faith and fair dealing, breach of contract, and violation of California's unfair business practices law.

She is represented by Michael McShane and Ling Kuang of the San Francisco firm Audet & Partners.Anthem spokesman Darrel Ng said in an email that he was not familiar with the case.

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