HIV advocates call plans from insurer Blue Cross NC ‘discriminatory’

Rachel Crumpler

More than 35 thousand According to the most recent data available from the North Carolina Department of Health and Human Services, North Carolinians are living with HIV.

These people are living longer and healthier lives thanks to drugs that treat HIV infection. For many, however, cost is a barrier to receiving such treatment.

Two HIV advocacy groups say that’s especially true for some potential and current patients covered by the state’s largest insurance company. North Carolina Blue Cross and Blue Shield.

The AIDS Action Network of North Carolina and HIV+Hepatitis Policy Institute in complaints filed last month in NC Department of Insurance and Office of Civil Rights at the federal Department of Health and Human Services.

He has 2022 and 2023 year Plans in the Affordable Care Act health insurance marketplace, Blue Cross NC, have placed nearly all HIV drugs in the most expensive drug categories (known in the insurance world as “tiers”). Several of the lower-priced drug options may not be used on their own or are older drugs that are no longer recommended, according to the complaint.

Karl Schmid, executive director of the HIV and Hepatitis Policy Institute, said the current insurance company practice of placing most drugs for medical conditions in the high cost tier is jeopardizing access to HIV prevention and treatment drugs in the state. He also said that this practice is infringing Affordable Care Act consumer protection against discriminatory plan.

Federal officials issued a stronger defense of the nondiscrimination plan last Maysaying that insurers’ drug lists, known as formularies, are “allegedly discriminatory when all or most drugs for a particular condition are placed at the level of expensive prescription drugs to discourage people with that condition from signing up.”

That’s what HIV advocacy groups believe is happening, and they’ve called on the Department of Public Health and the Office of Civil Rights at the federal Department of Health and Human Services to take action to ensure that those living with HIV and in the risks, had access to the treatments they needed.

Both offices acknowledged that they had received the complaint.

Blue Cross NC spokesman Jami Sanchez said the insurer is “responding appropriately” to the complaint. She went on to say that the company works with state and federal regulators annually to review its plans to make sure they comply with the law and will continue to do so.

“We take this very seriously and oppose discrimination of any kind, including discrimination based on health, sexual orientation or gender identity,” Sanchez said in a statement, adding that the methodology used to determine drug levels for drugs members of the Affordable Care Act is matched based on health status using clinical and cost information.

Not a new problem

Schmid said that discriminatory plans by insurers are nothing new. Plans that either don’t cover the drugs needed to treat HIV or provide such coverage by requiring patients to pay large out-of-pocket costs have been a problem for years — a problem that continues to surface, he said. Groups have filed complaints against numerous insurers in the states of the United States.

A 2015 study found that a quarter of the insurance plans the researchers analyzed used discriminatory drug classifications for HIV drugs. People covered by these plans paid an average of three times as much for HIV drugs, or several thousand dollars more per year, than they paid in nondiscriminatory plans

In 2014, Schmid, at that time the deputy executive director of AIDS Institutehelped file complaints against four Florida insurers to place all HIV drugs, including generics, in the highest drug categories, forcing patients to pay high out-of-pocket costs. Ultimately, insurers reclassified many drugs into lower cost tiers, he said.

The same outcome Schmid hopes will happen with Blue Cross NC — that drugs are tiered for greater availability.

“It’s a more measured approach,” he said.

High out-of-pocket costs

Alison Rice, professor emeritus of law at Duke University, said this is not the first year Blue Cross NC has included the vast majority of HIV drugs in the top drug category of its Affordable Care Act plans. In his previous role as director Duke Law Health Clinicshe produced annual reports on statewide HIV coverage, tracking the practices of insurers.

Rice said Blue Cross NC has one of the most expensive plans on the market for people with HIV.

“Not only do they have top-tier drugs, but the cost-sharing for those drugs is very high,” she said.

In 2021, coinsurance for top tier drugs increased from 25 percent to 50 percent for most plans.

“Obviously when they look at this, their priority is not to give people living with HIV easy access to affordable medications,” Rice said, adding that a 50 percent coinsurance can be a significant amount if the treatment regimen HIV can cost a couple thousand dollars a month on average.

In comparison, Rice said, insurers such as Cigna, UnitedHealthcare and Aetna carry a range of lower-tier HIV drugs and charge more reasonable co-pays.

A spokesman for Blue Cross NC said the insurer pays, on average, more than 80 percent of its members’ drug costs for the highest tiers. She said that when used to prevent HIV, the generic pre-exposure prophylaxis drug (known as PrEP) Truvada is available for free, regardless of whether it is in a higher drug tier. Under the Affordable Care Act, PrEP should be free on virtually all health insurance plans.

Need for affordable medicines

Recommended treatment for everyone with HIV antiretroviral therapy, which uses drugs to treat HIV infection. These drugs do not cure HIV, but they turn the disease—once a sure death sentence—into a chronic, manageable condition. Taking medicine too reduces the risk of spreading the virus to patients others.

Without treatment, HIV can gradually destroy the immune system and progress to AIDS, the most advanced stage of HIV infection.

Christina Adeleke, AIDS North Carolina’s director of policy and communications, is concerned that Blue Cross NC is making necessary HIV medications unavailable to some people, which could put their health at risk.

“I see people making the decision to forgo treatment to make sure their car is paid for and their rent is paid,” Adeleke said. “I hate to think about it because obviously you need to be alive to live life and you need medicine to live life.”

Rice said high out-of-pocket drug costs will mostly affect middle-class people who don’t qualify for federal and state programs that cover the cost of HIV drugs.

HIV advocacy organizations also worry about high out-of-pocket costs that increase existing health disparities. In accordance with AIDSBlacks and Latinos account for 58 percent and 13 percent of new HIV diagnoses, far higher than their share state population, but only account for 26 percent and 6 percent of HIV PrEP users.

Years research shows that patients’ out-of-pocket costs can create barriers for people to start and stay in treatment. Cost-sharing has been found to lead to higher rates of non-starters, people leaving their medicines at the pharmacy once they know the cost, lower adherence and more frequent drug discontinuation.

Adeleke added that available HIV drugs are not only in the interests of those living with the disease.

“If people don’t get treatment and can’t suppress the virus, that leaves them in a situation where they can physically transmit HIV to others, which is something we don’t want,” she said. “For the wider public health of society, it’s in our best interest that people can get treatment and stay in treatment.”

Even if costs are reduced, Rice said, another issue not addressed in the complaint is the continued trend toward narrowing provider networks. Some people living with HIV find that their long-time HIV provider is no longer in network, meaning they must either start with a new provider or drop their insurance.

“The Affordable Care Act has really improved access and health care for people living with HIV and many others, but there are still some challenges,” Schmidt said. “That’s why we have insurance commissioners and enforcement.”