MIAMI -- Patient advocates said some insurance companies are making HIV and AIDS drugs unaffordable in plans issued through the Patient Protection and Affordable Care Act by shifting much of the cost to customers.
While the issue applies broadly to all patients with chronic illnesses that require expensive medication, HIV and AIDS advocates said they were the first to file a formal complaint with the government about pricing.
Under President Barack Obama's health law, insurance companies are forbidden from turning away consumers with pre-existing conditions. But advocacy groups said insurance companies are discouraging HIV and AIDS patients, who are expensive to cover, by requiring them to pay a percentage of costly medications instead of a flat co-pay, essentially pricing the medications out of reach.
Several insurance companies are also impeding access to services by requiring reauthorization for drugs that consumers have been taking for years or making the claims process difficult, said Carl Schmid, deputy executive director of the AIDS Institute. The group filed a complaint with U.S. Health and Human Services Department officials this summer against four Florida insurance companies, and advocates in other states are considering similar action.
The complaint filed with federal health officials alleged Humana, CoventryOne, Cigna and Preferred Medical are violating the federal health law by discouraging consumers with HIV and AIDS from choosing those plans because they wouldn't be able to afford the high co-insurance rates.
Georgia advocates are planning to file a similar complaint with federal officials, said Dr. Melanie Thompson, who has several patients who are unable to afford the medicines under their new insurance plans. Advocacy groups said they are finding similar problems with some exchange plans in Ohio, California and Illinois.
The Health and Human Services Department said it's reviewing the complaint in Florida but declined further comment. Advocates said intervention by the federal government would also benefit patients who take expensive medications for chronic conditions such as blood cancer and rheumatoid arthritis.
The problem arises from how drugs are priced by insurance companies. For most drugs, consumers pay just a fixed amount, usually about $30 to $45 a prescription. However, insurance companies put some of the most expensive drugs in a special category, requiring patients to pay as much as 50 percent of the total cost.
While insurance companies face high costs in treating many cancer and hepatitis patients, the costs are more acute when a patient has a chronic, incurable health issue -- for example HIV or multiple sclerosis -- because they will have to take the expensive medications for the rest of their lives.
"By putting the drugs that are recommended up on the highest tiers in an unaffordable place, they are in essence discriminating against people with HIV because these are the lifesaving drugs they require to survive," Thompson said.
The Affordable Care Act bans insurers from charging an individual more than $6,350 in out-of-pocket costs a year or more than $12,700 for a family policy. But patient advocates warn that those with serious illnesses could pay their entire out-of-pocket cap before their insurance kicks in any money. Money paid toward premiums doesn't count toward the caps.
The AIDS Foundation of Chicago said HIV medications are likely unaffordable in plans offered by Aetna, Coventry, Health Alliance and Humana. In most cases, medications were placed on the highest tier, requiring co-insurance as high as 50 percent, which could cost a patient more than $1,100 a month for Atripla, a common, three-drug regimen.
The organization complained about the situation in a letter to state insurance officials. The state responded last month with a bulletin notifying insurers that plans can be considered discriminatory if they impose unreasonable prescription restrictions or require pre-authorization for refills without justification.
Insurance companies said their plans follow the latest guidelines, cover all medically necessary HIV drugs and offer a variety of choices.
But insurers said drugmakers are charging increasingly exorbitant prices for medications, according to Brendan Buck, with the trade group America's Health Insurance Plans.
State and local groups such as the AIDS Drug Assistance Program and Ryan White Program help patients with prescription drug costs but typically focus on the uninsured and underinsured.
Drew Dalire, 43, was in good health when he bought a plan in December from Humana under the Affordable Care Act, but he was diagnosed weeks later with HIV. He said he found out his three-drug regimen would cost about $1,800 a month after his $500 deductible.
Humana eventually let the Orlando, Fla., resident drop the plan and enroll with another insurer that he said offers better coverage.
A Section on 08/07/2014