D.C. officials stopped insurer from adverse tiering of HIV drugs

An insurer operating in the District of Columbia was discriminating against its members with HIV by requiring them to pay disproportionately expensive copays to treat their condition, the Washington Blade reported.

It took three D.C. agencies' "aggressive steps" and "extensive discussions" to stop the insurer's practice of adverse tiering of its HIV drugs, Mila Kofman, executive director of the D.C. Health Benefit Exchange, told the Blade.

After working with the insurer, Kofman said it reviewed and changed its formulary. "And so what they did was they moved the HIV medications to the generic or the preferred tiers. So anything that's not injectable they moved to the tiers that would result in low co-payments and the lowest co-insurance for patients," she explained.

Kofman wouldn't identify the name of the insurer, saying her main intention was to persuade the company to end its adverse tiering practice. "It could have happened with any insurer," she said. "So I'm not sure naming a particular company is helpful because they changed their policy."

But the Blade article hinted that the insurer in question could have been Aetna, based on a Health Affairs piece discussing a consumer with HIV who said he was forced to pay excessively high co-insurance payments under his Aetna plan.

Although it violates the Affordable Care Act, the adverse tiering policy has become increasingly popular among insurers looking to get around the law's provision that states insurers can't discriminate against individuals with certain medical conditions.

An Avalere Health analysis found that insurers have been known to place costly HIV drugs on the highest drug tier. For example, Consumer Watchdog has accused Cigna of requiring its members with HIV/AIDS to get medications from its mail-order pharmacy. And UnitedHealth settled a national class-action lawsuit in 2014 by agreeing to allow patients with HIV or AIDS to opt out of a requirement to obtain medications by mail order.

After facing harsh scrutiny for placing HIV and AIDS prescription drugs in the highest category of cost sharing, Aetna reduced out-of-pocket costs for these pricey medications.

To learn more:
- read the Washington Blade article
- here's the Health Affairs article