Healthcare Exchanges Unable to Cover Cost of HIV Drugs

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Healthcare Exchanges Unable to Cover Cost of HIV Drugs

By John Lavitt 02/12/15

Some insurance companies are forcing patients to pay more for HIV drugs, a practice that is illegal under the ACA.

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A new study in The New England Journal of Medicine has revealed the grim reality that essential drugs needed to treat HIV and AIDS are being priced out of reach for the majority of insurance plans through the new healthcare exchanges.

Despite such pricing practices being illegal under the Affordable Care Act, Harvard researchers found a frightening number of patients are being left in no man’s land. In this black hole of ACA coverage, affording proper treatment becomes impossible for patients who need the medicines.

Examining 48 health plans in 12 states, the Harvard team found that a quarter of the plans showed evidence of “adverse tiering,” a term used by the researchers to describe the placement of all the drugs used to treat HIV in a specialty tier where consumers are required to pay at least 30% of the cost. Beyond being illegal, the financial impact is extreme to say the least.

For example, a patient taking a common HIV treatment, Atripla, would pay about $3,000 more a year in a restrictive plan compared with someone enrolled in a more generous plan. Despite the fact that the more restrictive plans charge lower monthly premiums, the 30% payment increase puts the drug out of reach of anyone without significant financial resources.
“Insurers have historically used tiered formularies to encourage enrollees to select generic or preferred brand-name drugs instead of higher-cost alternatives," said lead author Douglas B. Jacobs. "But if plans place all HIV drugs in the highest cost-sharing tier…(It is really designed) to deter certain people from enrolling in the first place.”

The study ignored gold and platinum plans and focused instead on mid-level plans, which are the most popular among consumers. Although more generous in coverage, the higher premiums of these plans are not affordable by the majority of customers. By creating this illegal tiered formula, insurers are enforcing their belief that such gold and platinum plans are a better choice for people who have serious medical conditions.

Health insurers are prohibited from discriminating against specific medical conditions under the Affordable Care Act. Although the law contains provisions to help prevent such practices, the question of effective enforcement remains up in the air.

The Obama administration has told insurers that companies that place most or all drugs that treat a specific condition like HIV on the highest-cost tiers will be prosecuted. The question now is whether such warnings will become a reality.

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