Are ACA Exchange Plans Fair to People Living with HIV/AIDS?

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

On April 25th, Avalere Health published a comprehensive study on marketplace exchange plan formularies offered under the Affordable Care Act ("ACA"); it includes a cross-condition analysis addressing formulary coverage, cost sharing and access. The study, which was prepared for the Pharmaceutical Research and Manufacturers of America® (PhRMA), suggests that certain disease classes -- including HIV/AIDS -- experience bias under many of the plans.

Most of the law’s major provisions were phased in by January 2014, with other provisions phased in by 2020. The ACA has numerous implications generally on the United State’s health care delivery system, but more specifically on the access to healthcare afforded to people living with HIV/AIDS, as well Viral Hepatitis. What’s more, ongoing Medicaid expansion and the implementation of insurance exchanges will also impact nearly all health care providers, as well as their patients.

According to the Avalere study, formulary access for patients with HIV/AIDS has expanded though other barriers remain. The study included the following summary:[1]

Classes Included:

• Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs), Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTIs), Protease Inhibitors (PIs), and HIV-Other

Coverage for Key HIV Classes:

• In high-enrollment states, the average exchange plan covers at least 43 of 51 HIV/AIDS medications
• Single-source products in the therapeutic area appear on formulary at least 65% of the time in all states other than Utah, which has coverage 25% of the time

Utilization Management for HIV Classes:

• Exchange plans have continued to reduce their use of UM for HIV/AIDS medications. Now, exchange plans use UM less frequently than employer plans for these medicines

Tiering and Cost Sharing for Key HIV Classes:

• Preferred placement has increased for HIV/AIDS medications in 2016 exchange plans, though employer plans still use the specialty tier far less often than exchange plans do. And, a portion of plans continue to place all HIV drugs on the specialty tier
• Copays are common across HIV classes, with an average copayment of $66. When used, coinsurance is 35% on average

Photo Source: PhRMA

One of the more alarming findings demonstrates that many of the marketplace exchange plans require high cost sharing, which could be discriminatory. In 2016, about 1 in 10 health plans are placing all HIV medicines in certain classes on the specialty tier.[2]

This discriminatory practice took center stage in 2014, when four insurance carriers were sued by the National Health Law Program (NHeLP) and the AIDS Institute. The complaint charged “inordinately high co-payments and co-insurance for medications used in the treatment of HIV and AIDS" against Coventry Health Care Inc., Cigna Corp., Humana Inc. and Preferred Medical.[3]

Additional findings include:[4]

• In states with high exchange enrollment, average plans cover at least 43 of 51 drugs.
• Across classes, plans cover HIV/AIDS innovators at least 76% of the time, except Utah.
• In 2016, exchange plans use Prior Authorization for HIV meds less often than before, but still more than employer plans.
• Exchange plans’ placement of HIV/AIDS drugs on the preferred tier rises to more than half of the time in 2016.
• Copays are more common than coinsurance, though when used, coinsurance averages 35%.
• Exchanges have lower coverage for STRs than for other single-source NTRIs.
• Ten percent or fewer plans in 44 states and D.C. require coinsurance above 30% for all covered NNRTIs.
• New Jersey has the highest proportion of plans requiring coinsurance of 30% or more for all covered NRTIs.
• Alaska, Minnesota, and New Jersey have the highest percentage of plans requiring coinsurance above 30% for all protease inhibitors.
• Coinsurance above 30% for all covered therapies in HIV-other class is most common among plans in Alaska, New Jersey, Utah.

The ACA has largely benefited patients living with HIV/AIDS by expanding access to care, and lowering the ranks of the uninsured and under-insured. That said, despite some marked improvements in many exchange plans there remain ongoing barriers facing too many patients. Among them, higher deductibles, co-payments and co-insurance.

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[1] Avalere Health, "PlanScape® Review of Patient Access to Medicines in Exchange Plans, By Condition," p. 62, April 2016.

[2] Pharmaceutical Research and Manufacturers of America®, "New Avalere Study: Health plan formularies continue to suggest bias against individuals with certain health conditions," April 2016.

[3] Insurance Business Magazine, "Insurers accused of HIV discrimination in ACA marketplace," June 3, 2014.
[4] Avalere Health, "PlanScape® Review of Patient Access to Medicines in Exchange Plans, By Condition," p. 63-73, April 2016.