Access to HIV/AIDS Medicines in Exchange Plans

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

The ADAP Advocacy Association earlier this week announced the framework for its 9th Annual Conference, which includes seven (7) town-hall style panel discussions about various issues impacting access to care and treatment for people living with HIV/AIDS. Among them, a discussion on the access to HIV/AIDS medicines (and other services) in exchange plans.

The panel on the "Affordable Care Act: Marketplace Cost Sharing & Barriers to Healthcare" will be moderated by Scott Evertz, former Director for the Office of National AIDS Policy, and current board member for the Community Access National Network (CANN). It is an opportunity to dig deeper into the ongoing discriminatory practice by insurance companies, requiring inordinately high co-payments and co-insurance for medications used in the treatment of HIV and AIDS.

This ongoing issue has routinely been covered by the ADAP Blog, because it is one of the most commonly expressed concerns by the patient community. View previous blogs on the topic here, here, and here, as well as here.

The Pharmaceutical Research and Manufacturers of America® (PhRMA) recently released several new fact sheets, which provide an in-depth, state-by-state look at coverage and access in the 2016 exchange plans. In a statement released by PhRMA, they are summarized as follows: "From deductibles and cost sharing to prescription drug coverage and formulary data, each fact sheet lays out the specifics for a given state compared to the national average, according to research analyzing 2016 silver health insurance exchange plans. Based on the data and information gathered, the fact sheets also include suggestions for improving exchange coverage in each state."

The fact sheets are available online at AccessBetterCoverage.org.

Photo Source: AccessBetterCoverage.org

Of particular interest to our readers is the fact sheet on HIV/AIDS medications, outlined in the Formulary Access for Patients with HIV/AIDS. A troublesome finding is approximately 10% of the plans use high tier placement or coinsurance for all single source HIV medicines.[1]

An excellent patient-centric resource available at AccessBetterCoverage.org is the "In Your State" tool. It allows patients to learn more about the marketplace plans in each state, including important fact sheets.

For example, in Alabama the following actions are recommended:[2]

• Enforcing non-discrimination requirements, which apply to benefit design and provider networks; 
• Establishing stronger rules regarding exceptions and appeals processes, which help enrollees get the medicines and care their doctors recommend; and  
• Enhancing the state's marketplace website or advocating for a Healthcare.gov page that allows for easier plan comparisons, including searchable formularies and estimates of total out-of-pocket costs.

To utilize this tool, CLICK HERE.

The rising share of patient cost-sharing is widely viewed as the next frontier in the healthcare reform battle. It is one that disproportionately impacts people living with chronic conditions, such as HIV/AIDS.

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[1] Avalere, "Formulary Access for Patients with HIV/AIDS," page 9, 2016.
[2] AccessBetterCoverage.org, "In Your State: Alabama," 2016; available online at http://accessbettercoverage.org/states/alabama.