Plaintiffs M.D., C.F., and E.M. (the “Class Representatives”), on behalf of themselves and the Settlement Class Members, allege that Centene violated the law by instructing related entities to use fibrosis restrictions to limit access to hepatitis C drugs to those with advanced liver scarring. M.D., C.F., and E.M. have brought claims against Centene for violations of federal law and Florida contract law.Top
In a class action, one or more people called class representatives sue on behalf of people who have similar claims. All those people together are a class or each is a class member. One court resolves the issues for all class members, except for those who opt-out and exclude themselves from the class. Judge James Lawrence King is the judge in charge of this class action.Top
Centene moved to dismiss the claims set forth in the Class Representatives’ Complaint, arguing that the Plaintiff’s claims were moot because Centene had eliminated the disputed coverage guidelines effective July 1, 2018 and raise a number of other bases for dismissal. Centene believed that its motion to dismiss would succeed, defeating many of the Class Representatives’ claims. After months of negotiation, the Parties agreed to the Settlement rather than continuing to litigate. That way, they avoid the significant cost and uncertainty of the Court’s ruling on the motion to dismiss, other motions, and of a trial, and the people affected get relief.
Counsel for the Class Representatives and the Settlement Class Members have considered the substantial benefits from the proposed Settlement and balanced those benefits against the risk of no favorable outcome on the relevant claims after contested dispositive motions, trial, and likely appeals, which would take a considerable amount of time to resolve. From Class Counsel’s perspective, because this case is about treatment of hepatitis C, the risk of lengthy litigation did not outweigh the benefit of immediate settlement.
The parties and their attorneys think that the Settlement is fair, reasonable, and in the best interest of all Settlement Class Members.Top
You are a Settlement Class Member if: (1) you are or were covered under any individual health insurance plan or policy with a medical benefit or prescription drug benefit (or both) insured or administered by any Centene-related Entity; (2) while your coverage was in effect, your request for prior authorization for coverage of hepatitis C was denied based on a Metavir score or level of fibrosis between October 1, 2014, and December 31, 2018; and (3) you have not subsequently received direct acting antiviral therapy.Top
A. Agreement Not to Reinstate Fibrosis Restrictions
Effective on or around July 1, 2018, Centene eliminated fibrosis restrictions from its individual health insurance guidelines for hepatitis C medical coverage. Under the terms of the Settlement, Centene agrees not to reinstate those fibrosis restrictions as a basis to deny coverage for hepatitis C drugs. Centene will make reasonable attempts to provide notice to Settlement Class Members that there is no longer any fibrosis restriction in the coverage policy for hepatitis C drugs, and to advise them that they may resubmit their request for coverage if they currently have an individual insurance plan or policy through one of Centene’s subsidiaries. Settlement Class Members may make new requests for coverage of hepatitis C drugs and be granted such coverage a maximum of two additional times.
The agreement not to reinstate the fibrosis restrictions is without prejudice to Centene’s ability to subsequently review the coverage policy periodically, based on scientific analysis or requirements of governmental or other Plan sponsors, for potential modification.
B. Enrollment in Centene Plans
Any Settlement Class Member previously denied coverage for hepatitis C drugs who is no longer a member of one of Centene’s subsidiaries, will be given the opportunity, to the extent legally possible, to enroll in an individual plan by a Centene-related entity in the Settlement Class Member’s state. Settlement Class Members may visit www.ambetterhealth.com to learn more about any individual plans offered in their State. Centene shall not be responsible for paying any Class Member’s premium for enrollment in a Centene-related entity individual plan.
C. Payments to Settlement Class Members
Centene has agreed to make payments to certain Class Members who submit claims to the Claims Administrator and meet the following criteria. Settlement Class Members will be eligible to submit a claim for a single payment of up to $2,200.00 if they a) are no longer covered by a Centene-related entity and are uninsured; b) have no coverage of direct acting antiviral therapy; or c) cannot enroll with a Centene-related entity. The Class Members may use the payment in any manner he or she wishes. Centene will pay on a claims-made basis up to a total of $125,000.00. Class Members who meet these criteria may submit claims to the Claims Administrator by clicking HERE.
As part of the Settlement, the Settlement Class Members would release all Centene-related entities from all past, present, and future claims, actions, or demands arising from Centene’s denial of coverage for hepatitis C drugs based on Centene’s fibrosis restrictions, or from any claims asserted or which could have been asserted in this Action. The complete Settlement Agreement, including the full text of the release, is available by clicking HERE. If you have questions regarding the release, then you should review the complete Settlement Agreement.
The Court presiding over this case must decide whether to approve the Settlement. The Settlement will take effect only if the Court approves the Settlement, and if there are any appeals, after appeals are resolved.
The Court appointed the law firm of Rivero Mestre LLP in Miami, Florida, to represent you and other Settlement Class Members. These lawyers are called Class Counsel. You will not be charged for these lawyers’ work. If you want to be represented by your own lawyer, you may hire one at your own expense.Top
The parties negotiated the payment of attorneys’ fees and costs, separate and apart from the class relief, only after reaching agreement upon all other terms of the Settlement. Moreover, the Settlement is not contingent on the award of any particular amount of attorneys’ fees and costs, or incentive payments. Like all class action settlements, the amount of attorneys’ fees and costs awarded to Class Counsel is left to the discretion of the Court. The Parties have agreed that separate and apart from the relief Centene will provide to the Settlement Class, and subject to Court approval, Centene will pay an award of attorneys’ fees and costs up to $350,000 to Class Counsel, less any amounts the Court approves as incentive awards to the Class Representatives. Class Counsel will apply for incentive awards in the amount of $1,500 to each of the three Class Representatives.Top
Unless you exclude yourself, you will remain in the Settlement Class, which will mean that you cannot sue, continue to sue, or be part of any other lawsuit against Centene for the matters resolved by the Settlement, including any individual claim for damages or other monetary relief. It also means that all of the Court’s orders will apply to you and legally bind you. If you don’t want the benefits of this Settlement, you want to keep the right to sue or continue to sue Centene on your own, or you simply don’t want to be part of the Settlement, then you must take steps to exclude yourself from the Settlement Class.
The Settlement does not adversely affect any non-class members who are Centene policy holders and will not limit their future claims. If such non-class members contract hepatitis C and their medical provider applies for pharmaceutical treatment, the same revised policy described above, not utilizing the fibrosis restriction scores, will apply to them. Moreover, Centene-related entities, consistent with the intent of the Settlement, have notified medical providers who are likely to order hepatitis C pharmaceuticals, such as hepatologists, gastroenterologists, and infectious disease practitioners to notify them of the change in policy so it can be applied to Class Members and non-class members, alike.Top
If you come within the Settlement Class definition, you will be a Settlement Class Member and will be bound by the Settlement if the Court approves it, unless you exclude yourself from the Settlement Class (also known as “opting out”). Being “bound by the Settlement” means that you will be precluded from bringing, or participating as a claimant in, a similar lawsuit, including any suit for damages or other monetary relief arising from or in any way related to any Centene-related entities’ denial of prior authorization for hepatitis C drugs. Persons who exclude themselves from the Settlement Class will not be bound by the terms of the Settlement and will retain the right to sue Centene for any claims they might have, at their own expense.Top
To exclude yourself from the Settlement Class, you must mail a letter, postmarked no later than January 15, 2020, to the Settlement Administrator at PO Box 43501 Providence, RI 02940-3501, providing a signed statement that you want to be excluded from the Settlement. You must include your full name, address, and telephone number. If you are excluded from the Settlement Class, you will not be legally bound by anything that happens in this lawsuit; however, you also cannot object to the Settlement. In determining whether you want to exclude yourself from the Settlement Class, you are advised to consult your own personal attorney, as there may be issues particular to your circumstances that require consideration.Top
If you do not exclude yourself from the Settlement Class, you can give reasons why you think the Court should not approve the Settlement, and the Court will consider your views. To object, you must mail a letter, postmarked no later than January 15, 2020, to the Clerk of the Court, United States District Court, Southern District of Florida, 99 N.E. Fourth Street, Miami, Florida 33132, stating that you object to the Centene Hepatitis C Drug Settlement. You must include your full name, address, telephone number, the reason you object to the Settlement, and any evidence or other materials you want the Court to consider. You also must mail your objection to the following attorneys: (1) RIVERO MESTRE LLP, c/o Andres Rivero, 2525 Ponce de Leon Boulevard, Suite 1000, Miami, Florida 33134; and (2) Hogan Lovells LLP, c/o Marty Steinberg, 600 Brickell Avenue, Miami, Florida 33131. If your objections do not meet all of the requirements set forth in this section and the Settlement Agreement, they will be deemed invalid and will be overruled.Top
Subject to approval of the Court, any objecting Settlement Class Member may appear, in person or by counsel, at the Final Approval Hearing held by the Court, to show cause why the proposed Settlement should not be approved as fair, adequate, and reasonable, or object to any motion for attorney’s fees, costs, expenses, or incentive awards. The objecting Settlement Class Member must file with the Clerk of the Court and serve upon Class Counsel and Centene’s Counsel (at the addresses listed above), a notice of intention to appear at the Final Approval Hearing (“Notice of Intention to Appear”) on or before January 15, 2020.
The Notice of Intention to Appear must include copies of any papers, exhibits, or other evidence that the objecting Settlement Class Member (or his or her counsel) will present to the Court in connection with the Final Approval Hearing. Any Settlement Class Member who does not provide Notice of Intention to Appear in complete accordance with the deadlines and other specifications set forth in this Notice will not be allowed to speak or otherwise present any views at the Final Approval Hearing.Top
No. You are not required to come to the hearing but you are welcome to come at your own expense.Top
The Court will hold a hearing to decide whether to approve the Settlement on May 5, 2020 at the James Lawrence King Federal Justice Building, 99 N.E. Fourth Street, Courtroom 2, Miami, Florida 33132 (“Final Approval Hearing”). At the Final Approval Hearing, the Court will consider whether the Settlement is fair, reasonable, and adequate, and also will consider Class Counsel’s motion for attorney’s fees, costs, expenses, and incentive awards. If there are any objections, the Court will consider them at the Final Approval Hearing. After the Final Approval Hearing, the Court will decide whether to approve the Settlement. We do not know how long it will take the Court to issue its decision.Top
The mailed notice and this FAQ Section only summarizes the proposed settlement. The official terms of the proposed settlement and other case documents can be accessed by clicking HERE. You may also contact the settlement administrator with questions. All of the settlement administrator contact information can be found by clicking HERE.
Please DO NOT Contact the CourtTop