• Home
  • About
  • Contact Us
  • Home
  • About
  • Contact Us
Health exchange plans limit patient access to HIV drugs: study
November 11, 2015 4:49 PM
pic thx to trygve ulst on flickr creative commons

pic thx to trygve ulst on flickr creative commons

For the past two years, patient advocates have complained that many insurers are trying to discourage HIV patients from enrolling in policies sold on health insurance exchanges created by the Affordable Care Act. Now, a new analysis provides fresh evidence that their concerns are justified.

Just 16 percent of the so-called silver exchange plans in 2015 cover all 10 of the most widely used HIV drug regimens. These also cost patients less than $100 per month per regimen, according to Avalere Health, a consulting firm that ran the analysis. There are four types of exchange plans ranked from the most expensive out-of-pocket costs to the least expensive – Bronze, Silver, Gold and Platinum.

But almost half of the silver plans,or 46 percent, include all 10 of commonly used regimens on their formularies, which are lists of drugs that receive preferred insurance coverage. This means a drug typically costs patients less. But many silver plans charge higher out-of-pocket costs for the HIV drugs, according to the analysis.

The findings are noteworthy because the vast majority of people who are in health insurance exchanges – 68 percent – are enrolled in silver plans. That works out to about 6.7 million people, according to Caroline Pearson, a senior vice president at Avalere.

Moreover, HIV drugs accounted for 9 percent of drug spending on exchange health plans last year, according to a report by Prime Therapeutics, a pharmacy benefits manager. More was spent on medicines to combat diabetes and hepatitis.

“There are persistent barriers to accessing HIV drugs in exchange markets,” Pearson said. “There’s definitely concern among [the health] plans that HIV patients can be expensive to cover and they don’t want to structure benefits to attract a disproportionate share of enrollees with HIV.”

We should note that the analysis was funded by Gilead Sciences, which makes most of the medicines used in the HIV regimens.

Pearson added that coverage and cost sharing requirements on the silver plans differ from insurance provided by employers. Employer-sponsored insurance typically does not place HIV drugs on so-called specialty tiers that force consumers to pay higher rates – generally, 40 percent to 50 percent of the cost.

We asked America’s Health Insurance Plans, the trade group, for comment and will update you accordingly. [UPDATE: An AHIP spokeswoman sent us this: “The report completely ignores any of the prices or cost associated with these treatments and the fact that health plans are covering the vast majority of the cost.” She also argued the plans are “comprehensive” by covering the widely used regimens, and that the analysis only reflects 2015 plans.]

Nonetheless, the findings did not surprise Carl Schmid, deputy executive director of The AIDS Institute, a patient advocacy group that has been urging federal officials to investigate concerns about discrimination against HIV patients in exchange plans.

“This is further proof that the problem exists around the country,” he said. “And it gives us further ammunition to push for change. We need non-discrimination regulations spelled out clearly.” The AIDS Institute led a coalition of 197 groups that this week urged Health and Human Services Secretary Sylvia Burwell to address discriminatory insurance benefit designs in a rule that implements the Affordable Care Act,

Last year, his group and one other, the National Health Law Program, filed a lawsuit charging four insurers with unlawfully discriminating against people with HIV and AIDS in their Florida health plans. The groups accused the insurers of placing all HIV medications, including generics, on specialty tiers.

Since then, Aetna agreed to lower costs nationwide, while Cigna, Humana and Preferred Medical agreed to do so in Florida. And the Florida Office of Insurance Regulation warned insurers not to overcharge patients for drugs next year.

Meanwhile, the Centers for Medicare & Medicaid Services, which oversees Obamacare, earlier this year responded to the concerns by saying it will scrutinize potentially discriminatory practices for drug benefits in exchange plans for 2016. Plans that place expensive drugs in tiers with high coinsurance or co-pays may be asked to justify their policies.

Print This Post Print This Post
AetnaAIDSCignaCMSDiscriminationGilead SciencesHealth ExchangesHHSHIVHumanaSylvia Burwell
Share

AIDS  / Pricing & Patient Access  / Uncategorized

Ed Silverman

You might also like

Pharmalot.. Pharmalittle.. As the weekend nears.. Catching up on Merck, Roche and..
November 13, 2015
Drug makers kept many clinical trial results a secret: study
November 12, 2015
CMS warns state Medicaid programs on hepatitis c drug restrictions
November 6, 2015
  • About Pharmalot

    Pharmalot is produced by Stat, a national publication from Boston Globe Media Partners that will launch online this fall with coverage of health, medicine and life sciences. Learn more and sign up for exclusive content at www.statnews.com, where Pharmalot will move after the launch.

    Ed Silverman, a senior writer at Stat, has covered the pharmaceutical industry for two decades and has closely followed the many hurdles facing drug makers as they move ideas from the laboratory to the medicine chest. He has previously worked at The Wall Street Journal, The Star-Ledger of New Jersey, New York Newsday and Investor’s Business Daily. Feel free to send tips and suggestions to ed.silverman@statnews.com Follow us on Twitter @Pharmalot and @StatNews. And sign up for the Stat newsletter here.
  • Categories

    • AIDS
    • Alzheimer's
    • Antibiotics
    • Antitrust
    • Biosimilars
    • Bribes
    • Cancer
    • Cholesterol
    • Clinical Trials
    • Compound Pharmacies
    • Counterfeit Medicines
    • Diabetes
    • Direct-to-Consumer Advertising
    • Drug Development
    • Executive Hiring
    • FDA
    • FTC
    • Generics
    • Hepatitis C
    • Insider Trading
    • Laboratory Tests
    • Layoffs
    • Legislation
    • Litigation
    • Marketing
    • Medicaid
    • Mergers and Acquisitions
    • Off-Label Promotion
    • Off-Label Promotoin
    • Over-the-Counter Medicines
    • Painkillers
    • Patents
    • Patient Privacy
    • Patient Safety
    • Pharmacy Benefit Managers
    • Pricing & Patient Access
    • Product Recall
    • Quality Control
    • Rare Diseases
    • Research & Development
    • Schizophrenia
    • Side Effects
    • Uncategorized
    • Vaccines
    • Whistleblower


© Copyright Pharmalot 2015. All Rights Reserved.