Patient Advocates Voice Concern Over Drug Benefit Plan Design
July 8, 2014
Katie Sullivan, MA
The Affordable Care Act (ACA) prohibits insurance companies from rejecting new customers based on their pre-existing health conditions. Yet, a recent report alleged that 4 Florida-based payers may have structured their prescription drug benefit plans in a way which does just that.

A complaint filed by the AIDS Institute and the health advocacy group National Health Law program with the HHS claims that insurers —including CoventryOne, Cigna, Humana, and Preferred Medical —  violated mandates of the health law by placing HIV/AIDS prescription and generic medications in the highest-priced drug tiers. The AIDS Institute conducted an analysis which determined that CoventryOne placed all HIV drugs, including generics, as Tier 5 medications – meaning patients would have a 40% co-insurance after a $1,000 Rx deductible, and most would require prior authorization. Cigna and Humana also placed all HIV drugs as Tier 5 medications, leaving patients with 40% and 50% co-insurances after deductibles respectively. Preferred Medical placed all HIV drugs on a specialty tier that incurs a 40% co-insurance.

“The QHP [quality health plan] drug benefits offered by CoventryOne, Cigna, Humana, and Preferred Medical impose overly restrictive utilization management which unduly limits access to commonly used HIV/AIDS medications,” read the groups’ statement. “Moreover, by placing all HIV/AIDS medications, including generics, on the highest cost-sharing tier, CoventryOne, Cigna, Humana, and Preferred Medical discourage people living with HIV and AIDS from enrolling in those health plans – a practice which unlawfully discriminates on the basis of disability.”

The 4 payers maintained that they are complaint with ACA mandates, but HIV/AIDS advocates aren’t convinced that state regulators have enforced them.

“A state insurance regulator doesn’t have the clinical expertise to know whether the common HIV drugs are covered and how they should be covered on a formulary,” says Katie Keith, director of research at the Trimpa Group, a consulting firm. “That’s why you need strong federal guidelines.”

Another analysis, which was conducted by Avalere Health, discovered that other patients with other chronic or serious medical conditions may also face similar cost-sharing problems. The group examined 123 health insurance exchange plan formularies throughout each state. They found that more than 60% of silver plans placed all covered medications for multiple sclerosis, rheumatoid arthritis, Crohn’s disease and some cancers in the highest formulary tier. The analysis also determined that as many a 35% of plans placed HIV/AIDS drugs in the highest tier.
Experts suggest that insurers have chosen to place these medications in higher tiers based on fear that they will have to cover a larger portion of chronically ill consumers.

“If your benefit is more generous than others you’ll get everyone with that illness,” said Dan Mendelson, CEO of Avalere Health.

Around the Web

Some Plans Skew Drug Benefits To Drive Away Patients, Advocates Warn [KHN]

NHeLP and The AIDS Institute Complaint to HHS Re HIV/AIDS Discrimination by Florida Insurers [HealthLaw]