Judge Likely to Side with Blue Shield in Coverage Dispute with Department of Managed Health Care
A Sacramento Superior Court judge issued a "preliminary judgment" yesterday siding with Blue Shield of California in its lawsuit alleging that the Department of Managed Health Care improperly required the HMO to pay for a weight-loss drug not covered in a member's contract, the San Francisco Chronicle reports. Judge Joe Gray is expected to rule on the case today, but the preliminary judgment indicated that he likely will side with Blue Shield (San Francisco Chronicle, 1/15). The case involves an obese woman whose doctors determined that she would die if she did not take the weight-loss drug XenicalJ. While her doctors contended that a new state regulation requiring any health plan that provides drug coverage to cover all "medically necessary drugs" compelled Blue Shield to pay for the treatment, the company refused, saying that outpatient weight-loss drugs were excluded from the woman's policy (California Healthline, 12/17/01). The DMHC then fined Blue Shield $100,000 after an independent review determined that the HMO should have covered the treatment. In his decision, Gray will decide whether to issue an injunction against the department and release Blue Shield from covering the drug and paying the fine. Steven Madison, the lawyer representing Blue Shield, likened the case to a ruling by a judge in July that the department could not force Kaiser Permanente to cover the impotence drug Viagra. "We won that case hands down, and the department went and did the same thing," he said. DMHC spokesperson Steve Fisher "admitted the preliminary judgment was not a good sign but delayed commenting until the decision is made" (San Francisco Chronicle, 1/15).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.