According to officials at AIDS Foundation of Chicago ( AFC ), only one insurer has so far responded to its letters expressing concern for coverage and cost of HIV medications on plans that are being offered on the Affordable Care Act ( ACA ) Marketplace. Federal officials, meanwhile, noted in their parameters for insurers participating in 2016 Marketplace coverage that such pricing could be construed as discriminatory.
AFC and AIDS Legal Council of Chicago officials wrote to four insurers—Humana, Coventry, UnitedHealthcare and Health Alliance—the week of Jan. 26. Those plans all placed HIV medications on a specialty tier, which usually results in customers having to absorb extremely higher costs in order to obtain that medication.
Only Coventry has so far responded to the letters, according to Ramon Gardenhire, vice-president of policy for AFC. He added that AFC officials will discuss the matter with the company next month.
"We are looking at all our options with this," said Gardenhire. "If we continue to be met with radio silence, we won't have a choice but to file a complaint with the Illinois Department of Insurance."
Insurers in numerous states, in 2014, adjusted formularies so that specific HIV medications are either not covered, or are available at substantially higher costs to customers. Coventry, for example, classified most single-tablet regimens as "tier 5," or non-specialty drugs, and refused to cover costs for the medication Tivicay, according to the AFC-ALCC letter.
In correspondence with Health Alliance Insurance, Gardenhire and ALCC Executive Director Tom Yates note that that company classified single tablet regimens and the medication Truvada as tier 5. The letter to Humana notes that the average monthly cost to a customer on their plan requiring HIV medications would be between $840.71 and $1628.94. For United Healthcare customers it would be between $720.61 and $977.19.
This is a nationwide issue. A study that appeared in January in the New England Journal of Medicine suggested that about 25 percent of persons with HIV/AIDS in the ACA marketplace might have been subjected to such pricing. The study analyzed 48 plans in 12 states.
Consumer groups lodged complaints against four Florida insurers with the Department of Health and Human Services in May 2014. Those companies eventually lowered their prices, but the complaint itself is still unresolved. In California, Kaiser Permanente announced Feb. 19 that it would remove HIV medications from its highest tiers and issue refunds to customers who had been adversely affected by pricing changes, according to Bay Area Reporter.
The federal government seemingly weighed in on the issue Feb. 20, when the Department of Health & Human Services' Center for Consumer Information & Insurance Oversight released its final 2016 final parameters for ACA marketplace insurers. The document says that many discriminatory situations have to be determined by authorities on a situational, case-by-case basis, but addresses tiered pricing that can be construed as de facto discrimination against persons with certain conditions.
"Having a specialty tier is not on its face discriminatory," according to the regulations, which would go into effect 60 days after they appear in the Federal Register, currently scheduled for Feb. 27. "However, placing most or all drugs for a certain condition on a high cost tier without regard to the actual cost the issuer pays for the drug may often be discriminatory in application when looking at the totality of the circumstances, and therefore prohibited. When CMS [Centers for Medicare & Medicaid Services] or the State requests a justification for such a practice, issuers should be able to identify an appropriate non-discriminatory reason that supports their benefit-design, including their formulary design."
AFC President/CEO John Peller said he and other officials were still analyzing the parameters, but called them "a strong statement against such practices."
The Illinois situation, in the meantime, is further complicated by indications in Gov. Bruce Rauner's budget, issued Feb. 18, that many low-income Illinoisans utilizing the AIDS Drugs Assistance Program would be shifted to the ACA Marketplace.
"As an organization, AFC has been embracing of the ACA," Gardenhire noted. "But the ACA does not have all the elements in place to uniformly help everyone."
Molly McAndrew, policy manager at AFC, added, "We often forget that the people we are talking about here are consumers. When they pay for a product—in this case, paying their premiums—there's a contract here and they are expecting something in return. With this 'adverse-tiering,' we have to consider whether insurers are breaking that contract."
