HIV discrimination complaints filed in five states against insurers for substandard drug coverage & high cost-sharing

Follows Similar Complaints in Texas and North Carolina

Washington DC… The HIV+Hepatitis Policy Institute filed five discrimination complaints against two insurers, Medica and Harvard Pilgrim, for offering plans that discriminate against people living with HIV. The insurers use several strategies to discourage enrollment by people with HIV, including placing all HIV drugs, including generics, on the highest cost tier, not covering drugs that are recommended by national treatment guidelines, including single-tablet regimens, and not meeting state essential health benefits benchmarks.

The Medica complaints were filed with the state insurance commissioners in the states of Iowa and Minnesota. The complaints against Harvard Pilgrim were filed in New Hampshire, Maine, and Rhode Island. 

In recent years, the HIV+Hepatitis Policy Institute filed similar complaints against North Carolina Blue Cross Blue Shield and Community Health Choice Texas.  The Texas case is still pending before the federal government, which regulates ACA plans in the state.

“We continue to uncover private insurers that engage in discriminatory plan design by using drug formularies that discourage enrollment of people living with HIV. Putting every HIV drug, including cheap generics, on the highest cost-sharing tier and not covering drugs necessary to treat HIV are blatant examples of discrimination,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “Without proper regulation and enforcement, some insurers will try to get away with whatever they can. We call on the state insurance regulators to act quickly on these complaints and immediately ensure these insurers come into compliance.”

Medica’s 2024 formularies in Iowa and Minnesota put all 31 HIV treatment drugs, including low-cost generics, on Tier 5, its highest cost specialty tier. (Two HIV drugs are on Tier 2 which cannot be used alone for the treatment of HIV but are used to treat hepatitis B.)

For 2025, Medica’s formulary places one generic single-tablet regimen on the proper tier, but that drug is rarely used due to its side effects. 

Since the copay for Tier 5 in Medica plans can be $500, $850, and even 50 percent coinsurance, depending on the plan, people living with HIV can face out-of-pocket costs higher than the list price of their drug.

Medica’s 2025 formularies also do not meet national HIV treatment guidelines since they only cover two of the four preferred regimens recommended for initial treatment of HIV and only one of four alternative regimens recommended for initial treatment in certain circumstances. 

Medica only covers four of the thirteen single-tablet regimens (STRs).  STRs allow people living with HIV to take just one drug per day instead of multiple drugs throughout the day.

CMS has made it clear to insurers that putting all or a majority of drugs on the highest tier is discriminatory while not following nationally recognized treatment guidelines and not covering STR’s are potentially discriminatory.

Medica’s formularies also fail to cover the minimum number of drugs in each class to meet Iowa and Minnesota’s essential health benefits benchmark plan.

The complaints against Harvard Pilgrim detail how the plans’ formularies for 2025 do not meet national HIV treatment guidelines by only covering two of the four preferred initial treatments of HIV and only two of the four alternative regimens for initial treatment.

Most significantly, Harvard Pilgrim is removing Biktarvy from their formulary, the most widely prescribed HIV drug in the U.S.  Many people currently on this drug as well as the other twelve drugs Harvard Pilgrim no longer covers will no longer be able to access their medication interrupting their continuity of treatment. They will have no choice but to change insurers.

Interestingly, Harvard Pilgrim’s equivalent formulary for Massachusetts follows treatment guidelines and covers all eight of the preferred and alternative regimens in national treatment guidelines, including Biktarvy.

The formularies in Maine and Rhode Island also fail to cover the minimum number of drugs in each class to meet the state’s essential health benefits benchmark.

Last year, the HIV+Hepatitis Policy Institute filed a complaint with CCIIO against Community Health Choice Texas for similar discriminatory plan designs. The insurer does not cover any single-tablet regiments that are recommended for initial treatment of HIV, removed Biktarvy from its formulary, and does not meet the state’s EHB benchmark.  Last month, we sent a follow-up letter to CCIIO to reiterate the insurer’s violations and to urge them to take immediate action.  Due to their inaction, the substandard and discriminatory plan design is being carried forward in the 2025 plans.

In 2022, HIV+Hep and North Carolina AIDS Action Network filed a discrimination complaint against North Carolina Blue Cross Blue Shield for placing almost all HIV drugs on the highest tiers, including generics.  Months after the complaint was filed, the insurer shifted 48 HIV drugs from the highest tiers, leaving none on those tiers, and removed all quantity limits.

HIV+Hep also submitted comments on CMS’ draft letter to issuers that detailed these substandard and discriminatory plans, voiced our disappointment with the lack of enforcement, and urged them and states to uphold the ACA’s patient protections, including its nondiscrimination regulations. 

The complaint to the State of Maine was also signed by the Frannie Peabody Center, HealthReach Community Health Centers, Maine General Medical Center, Consumers for Affordable Health Care, and Dr. Stephen Rawlins.

The complaint to the State of Rhode Island was jointly submitted with Open Door Health.

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The HIV+Hepatitis Policy Institute is a national, non-profit organization whose mission is to promote quality and affordable healthcare for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions.