BioMatrix's Litigation Information
Frequently Asked Questions
Q. Is what Highmark is saying about BioMatrix in its third amended complaint true?
A. Not at all. The BioMatrix pharmacies properly dispense life-saving medications to their patients, the costs associated with these medications are covered under Highmark’s policy, and Highmark is refusing to pay our patient’s legitimate claims. BioMatrix fulfilled its obligations to its patients and is now fighting for its patients to safeguard the benefits they are entitled to under the Highmark policy. Trying to use the cloak of litigation to avoid its legal, statutory, contractual, and moral obligations to its insured members will not work for Highmark.
Q. Did BioMatrix do anything wrong?
A. No, we did not. Because Highmark failed to live up to its obligations to its members by failing to pay BioMatrix for their benefits, we were compelled to file this lawsuit. As a specialty pharmacy that dispenses medication to treat hemophilia and other life-threatening diseases, BioMatrix is taking this action to hold Highmark accountable, stop them from refusing to pay for life-saving medications, and compel Highmark to make good on the promises it made to its insured members. Alleging 12 separate violations of federal and state law, BioMatrix filed its lawsuit to ensure that Highmark pays the more than $8 million in benefits that it owes its insured members and BioMatrix.
Q. Why was a lawsuit against Highmark necessary?
A. While litigation was not our first choice, Highmark’s refusal to live up to its commitments left us no choice. We are committed to helping our patients and their families get medication they need.
Q. What is BioMatrix trying to achieve through this lawsuit?
A. We have two parallel objectives. First, by alleging 12 separate violations of federal and state law, BioMatrix is enforcing its members rights to $8 million in benefits that Highmark owes them. And second, to stand in solidarity with our employees on behalf of our patients. We know all too well the financial and emotional impact that caring for people with hemophilia has – and we are not going to sit idle while a multi-billion dollar insurance company harms this community.
Q. Are BioMatrix’s patients at risk during this time?
A. Caring for our patients is our privilege and always our priority. As we have for decades, we take enormous pride in our responsibility to provide life-saving medications to people with hemophilia and other bleeding disorders – and we’ll continue to do so for our patients. We know that the BioMatrix pharmacies properly dispense life-saving medications, that the costs associated with these medications are covered under Highmark’s policy, and that Highmark’s refusal to pay our patient’s legitimate claims is wrong. Trying to use the cloak of litigation to avoid its legal, statutory, contractual, and moral obligations to its insured members will not work for Highmark.
Q. What is the background on this case?
A. As a multi-billion dollar insurance company, Highmark has violated the law, by attempting to rescind promised insurance coverage from 41 of its insureds, and their family members, with pre-existing conditions – with potentially life-threatening consequences. People with hemophilia rely on insurance coverage to get costly medical care and prescriptions that prevent them from bleeding to death. Not surprisingly, the Affordable Care Act (“ACA”) anticipated that insurance companies would target the expensive lifetime care that patients with pre-existing conditions need to survive – and put in place robust protections to stop this from happening. By way of background:
- The BioMatrix pharmacies contract with US Health Group and Atlantic Health Group to obtain care coordination and patient representative services to support the pharmacy business. Given the importance of trust among people with hemophilia, a number of US Health Group and Atlantic Health Group employees and/or their families have a personal connection to the hemophilia community.
- Highmark issued a Premier Balance PPO $0 Platinum policy with an effective date of November 1, 2017 to US Health Group and Atlantic Health Group – which together have fewer than 50 employees.
- Importantly, the ACA guarantees companies with under 50 employees the absolute right to purchase insurance based on a “community rating” specifically to ensure that no single patient population could be excluded or targeted for aggressively priced coverage.
- A primary goal of the ACA was to remove barriers to coverage for specific patient populations, such as lifetime caps, pre-existing conditions, and medical underwriting so that large insurance carriers could no longer target and exclude the expensive lifetime care that patients with pre-existing conditions needed to survive.
- Once insured by Highmark, many of US Health Group and Atlantic Health Group employees continued to purchase their life-saving clotting factor medication from Highmark’s in-network pharmacy, BioMatrix. Because they were free to use any pharmacy they wanted to, others did not use BioMatrix.
- After the policy became effective, Highmark began to receive claims for reimbursement for life-saving factor dispensed by the BioMatrix pharmacies as well as other medical and pharmacy claims. Highmark apparently views the policy for US Health Group and Atlantic Health Group as a money loser for them. This view is fundamentally wrong, as under the ACA the isolated profitability of individual small group plans is an inappropriate metric due to community rating. By definition, in order to comply with the ACA, some number of Highmark’s small group policies would have claims that exceed the premiums collected.
- Highmark acted illegally by attempting to rescind the policy it had issued in an effort to stop its losses – and now, to go even further, try to claw back already paid reimbursements.
Q. Doesn’t Highmark understand how expensive it is for people with hemophilia?
A. As our complaint against Highmark makes clear, they do understand this expense – which we believe is why they acted as they have. The level of claims Highmark incurred as a result of the policy they sold, and for which they were paid, apparently drove them to seek a way to avoid their obligation to their members and BioMatrix too.
Q. What happens next?
A. While we cannot speculate on what Highmark will say or do, BioMatrix will pursue the full breadth of its legal options and – with the support of BioMatrix employees – continue to advocate for the rights of patients with hemophilia to be sure that when an insurance company makes a promise, they keep it.