Aetna has changed how HIV drugs are listed within health plans sold on the exchanges after consumer groups criticized the health insurer's policy as discriminatory.
Many plans on the Affordable Care Act exchanges have been found to engage in “adverse tiering.” Although the ACA prohibits health insurers from denying care to someone with a pre-existing medical condition, some companies have crafted health-benefit designs that would deter sicker people from choosing the plans by imposing higher out-of-pocket costs.
In the case of Aetna's exchange plans, almost all HIV drugs are on the priciest specialty tier. Plan members with HIV faced coinsurance as high as 50%, resulting in almost $1,000 in monthly drug costs, according to the AIDS Institute. However, effective June 1, almost all HIV drugs across all of Aetna's exchange plans nationwide will be placed into lower-cost generic or non-preferred tiers.
The policy change will lower patient cost-sharing for HIV drugs to co-payments that range from $5 and $100, after deductibles are met, an Aetna spokeswoman said. Aetna also will consider revising drug lists for employer plans that don't already cover HIV drugs in lower-cost tiers.
“This is a major victory for people living with HIV who rely on medications to remain healthy,” said Carl Schmid, deputy executive director for the AIDS Institute.
Aetna's decision comes several months after Cigna Corp. and Humana changed their prescription drug policies to lower cost-sharing on HIV drugs. However, Cigna's and Humana's changes applied only to their exchange plans in Florida. The AIDS Institute and the National Health Law Program filed a complaint with HHS last year against Aetna, Cigna, Humana and Preferred Medical, alleging their drug formularies discriminated against HIV patients.
The CMS said in February that it will take a more critical approach to potentially discriminatory practices in the drug benefit designs of exchange plans in 2016. Insurers that place expensive drugs in tiers with high coinsurance or co-pays for members may have to justify their policy with regulators.
“Having a specialty tier is not on its face discriminatory,” the CMS said. “However, placing most or all drugs for a certain condition on a high-cost tier without regard to the actual cost the issuer pays for the drug may often be discriminatory in application when looking at the totality of the circumstances, and therefore prohibited.”
The harder stance from the CMS may have forced Aetna to make the drug formulary change before it files 2016 plans in the next couple months, Schmid said. But Aetna's change should be just a start, he said. More plans need to be held accountable for “trying to gouge the patients who rely on medications,” Schmid said.
Patients with hepatitis C and other diseases have similarly faced high prescription drug costs, even for generics.
“It shouldn't just be HIV drugs that they are doing this for,” Schmid said.