Following accusations in December of Blue Cross and Blue Shield of North Carolina violating a provision in the Affordable Care Act (ACA) by discrimination through health insurance plan design, the state’s largest insurer has removed 48 drugs from its costliest drug tiers.
The change is expected to allow patients to pay for HIV drugs at more affordable prices. In its midyear drug formulary (PDF), no HIV drugs remain on the costliest tiers of drugs, Tiers 5 and 6. The insurer also moved 19 generic HIV drugs to Tier 2 and removed quantity limits previously imposed on HIV drugs.
The HIV+Hepatitis Policy Institute said in a release it is not sure of the ongoing nature of the filed complaints with North Carolina AIDS Action Network, having received no formal communication from the North Carolina Department of Insurance nor the Office for Civil Rights at the U.S. Department of Health and Human Services (HHS). It’s not clear whether Blue Cross Blue Shield was fined or forced to make these changes.
The two advocacy organizations argued that Blue Cross Blue Shield’s 2022 and 2023 market plans violated the Affordable Care Act (ACA) by placing HIV drugs on the highest cost-sharing tiers through “adverse tiering.” This jeopardizes HIV prevention and treatment in the state, the groups argued, especially when several generic drugs were previously on Tier 5.
“While pleased to see this dramatic turnaround by the insurer, blatant discriminatory plan design and violation of the ACA’s patient protections should not happen in the first place,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “Insurers seem to try to get away with as much as they can until they are caught. For insurance to work for patients, we need better federal and state regulation, oversight, and enforcement. A drug formulary with adverse tiering should never be approved.”
Publicly available data in North Carolina show that Black people make up 58% of new HIV diagnoses in the state, versus 23.7% for white people. White communities are also far more likely to be on PrEP, or preexposure prophylaxis, than Black or Hispanic communities.
“Our people already face stigma and other barriers to care and treatment,” said Veleria Levy, executive director of the North Carolina AIDS Action Network. “While we are disappointed that it took a formal discrimination complaint and this practice went on for years, we are pleased to see that the ACA patient protections work, and people are protected from discriminatory insurance company practices. North Carolina BCBS still has plans that charge beneficiaries 50% cost-sharing for all but Tier 1 drugs, so it is important for people to select the plan that best meets their needs to take advantage of these plan changes.”
A new report from HHS found that in 2021, more than a quarter of Medicaid enrollees with HIV likely did not receive at least one critical service (medical visits, viral load tests and antiretroviral therapy prescriptions), with 11,000 enrollees having no evidence of ever receiving any critical services. Medicaid enrollees were more frequently missing critical services than dual-eligible enrollees.