November 13, 2015
In most states, consumers with HIV or AIDS who buy silver-level plans on the insurance marketplaces find limited coverage of common drug regimens they may need and high out-of-pocket costs, according to a new analysis.
In 31 states and the District of Columbia, silver-level plans cover fewer than seven of the 10 most common drug treatment options or charge consumers more than $200 a month in cost sharing, according to an analysis of 2015 silver plans by consultant group Avalere Health. Only 16 percent of those marketplace plans cover all 10 of the top HIV/AIDS drug regimens and charge less than $100 a month.
Silver plans are the most popular on the insurance marketplaces set up by the health law. They cover 70 percent of medical charges, on average, while consumers are responsible for 30 percent.
"It's just more ammunition showing that many plans are engaging in discriminatory plan designs," says Carl Schmid, deputy executive director at The AIDS Institute, an advocacy group based in Tampa, Fla. "It's not just Florida. It's happening around the country as well."
Last year, The AIDS Institute and the National Health Law Program filed a complaint with the Office for Civil Rights of the federal Department of Health and Human Services charging that four Florida insurers -- CoventryOne (which is owned by Aetna), Cigna, Humana and Preferred Medical -- were violating the anti-discrimination provisions of the health law by structuring their prescription drug plans so that they discouraged people with HIV/AIDS from applying. The four insurers placed all HIV medications, including generics, on the highest cost-sharing tiers, the groups alleged.
The Florida Office of Insurance Regulation eventually reached agreements with the four plans to move HIV/AIDS drugs from specialty to generic tiers and reduce cost sharing in 2015.
Coverage for HIV/AIDS drugs can vary widely, says Caroline Pearson, a senior vice president at Avalere who authored the analysis. "Typically plans have a relatively unified formulary state to state, but HIV is the exception," she says. "If you happen to be in a state that covers them well, you're well off."
For 2016, Pearson doesn't expect any big changes in drug coverage for people with HIV and AIDS.
"As consumers consider their options for 2016, it's likely the same barriers will remain," she says. "Consumers need to be thoughtful about plan selection."
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