Several Anthem/Blue Cross Blue Shield entities (Anthem) have alleged that Insys Therapeutics Inc. inappropriately incentivized physicians to write off-label prescriptions for its Fentanyl spray, Subsys, for which Anthem paid millions of dollars in unnecessary reimbursements.
In a civil lawsuit filed on July 12, 2017, Anthem alleges that patients needed pre-authorization to obtain Subsys, a powerful opioid, and Insys’s reimbursement team falsely represented that enrollees in the plans met the necessary criteria when they did not. Anthem alleges that Subsys is only intended for cancer patients who could tolerate opioids, but for whom other opioids did not work adequately. Anthem alleges that Insys developed a scheme – inducing physicians to prescribe Subsys for off-label uses – so that the drug, which was tailored to a narrow population, would generate more money. Anthem alleges that the Insys scheme increased off-label use and resulted in millions of dollars of payments which should not have been made because the medication was not covered.
The lawsuit, Blue Cross of California Inc., et al. v. Insys Therapeutics Inc., filed in the U.S. District Court for the District of Arizona, alleges fraud, civil conspiracy, unfair and deceptive business practices, and negligent misrepresentation. In addition to the civil lawsuit, criminal charges have reportedly been considered or filed against some former Insys executives and sales representatives.