Aetna Faces Class Action Lawsuit Over Mail-Order Requirement for HIV Drugs

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The plaintiff, John Doe, alleges that not having access to a community pharmacist will limit his ability to gain counseling on potential drug interactions. United Healthcare settled a similar action earlier in 2014. Consumer groups have also alleged discrimination against HIV patients by insurers over drug access in Florida.

For the second time in 2014, a national insurer has been sued by a California consumer group for requiring persons with HIV/AIDS to purchase prescriptions through its mail-order specialty pharmacy.

Aetna Inc. was sued December 19, 2014, about a month after sending notices to its California enrollees informing them of the policy change that will take effect January 1, 2015.

The unnamed plaintiff, John Doe, says in the suit filed in federal court that the change is discriminatory, because it will deprive HIV-positive patients of “essential counseling from an expert pharmacist at a community pharmacy who knows their medical history and who, working directly with patients in face-to-face interactions, is best positioned to detect potentially life-threatening adverse drug interactions and dangerous side effects.”

Persons with HIV/AIDS could elect to obtain their prescriptions from a community pharmacy. However, under the policy change, Aetna would consider that purchase out-of-network, which the suit alleges would cost patients “thousands of dollars more” each month. Prior to the policy change, co-payments were fixed at $20 to $70 per prescription.

The new program charges a 20% coinsurance, up to a maximum of $150 per prescription, which the suit alleges is discriminatory in itself.


Aetna official Cynthia Michener defended the program and the proposed changes in a statement. “As part of our ongoing strategy to do all we can to keep our health plans affordable and help with medication adherence, Aetna moved HIV medications to our specialty drug list. This list includes a number of high-cost medications that treat complex conditions that require close patient monitoring,” Michener said.

Earlier in 2014, United Healthcare faced a similar action and settled, agreeing to let HIV/AIDS patients who did not want to participate in a mail order program opt out through a simple procedure. United Healthcare and its specialty pharmacy also agreed to set up a designated toll-free customer service line to handle calls about the exemption process.

Consumer watchdog lawsuits have also occurred in Florida, where advocates had accused national insurers of overcharging HIV/AIDS patients for prescriptions or limiting their ability to obtain them under the Affordable Care Act (ACA), which gave some HIV-positive persons access to health insurance for the first time in their lives.

The ACA ban against barring persons with pre-existing conditions from obtaining coverage has been a game-changer for persons who have outlived the frightening early days of the disease, when diagnosis was the equivalent of a death sentence. Today, the CDC officially considers HIV a chronic condition, albeit one that requires a lifetime regimen of expensive medications.

In September, The American Journal of Managed Care published a well-read editorial by Gerry Oster, PhD, and co-editor-in-chief A. Mark Fendrick, MD, about an emerging pattern in which health plans have created higher-priced non-preferred tiers not only for drugs still on patent, but also for generic drugs. In some cases, non-preferred drugs included those for which there was no lower-cost alternative. HIV drugs were among those found to be priced in the non-preferred generic category in a survey by the authors.

The practice has caught the attention of Congress, which has noticed a sudden escalation in generic drug prices, with no obvious explanation.

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Second Florida Insurer Strikes Deal with State Over HIV Drugs