HIV organizations file discrimination complaints against North Carolina Blue Cross Blue Shield

Press Release

December 8, 2022

Plan Puts Almost All HIV Drugs, Including Generic PrEP, on Highest Tiers

Washington, DC & Raleigh, North Carolina… Today, the HIV+Hepatitis Policy Institute and the North Carolina AIDS Action Network filed discrimination complaints against Blue Cross and Blue Shield of North Carolina for placing almost all HIV drugs, including generic Pre-Exposure Prophylaxis (PrEP), on the highest drug tiers, thus forcing people living with and vulnerable to HIV to pay excessive high costs to take their drugs.

In two separate complaints filed with the North Carolina Department of Insurance and the Office of Civil Rights at the U.S. Department of Health and Human Services, the groups urge immediate enforcement action be taken against the insurer for designing its drug formulary in a discriminatory manner.  For both 2022 and 2023, Blue Cross and Blue Shield health plans place the vast majority of drugs used to treat and prevent HIV on the highest cost-sharing. This practice is known as “adverse tiering” and is in violation of the Affordable Care Act (ACA) patient protections.

The insurer uses a six-tier formulary and places almost all HIV antiretroviral medications on Tiers 5 and 6, which they define as the “highest-cost prescription medications.”  However, all brand-name single tablet regimens that are the standard of HIV care, along with several generics, are also on these tiers. This includes the only generic drug used as PrEP to prevent HIV.  While it is on Tier 5, it is marked as having $0 cost-sharing in compliance with the preventive services requirements of the Affordable Care Act.  There are some generic HIV drugs on lower tiers but none of them can be used on their own, and some of them are no longer recommended and not prescribed.

Drugs placed on the highest tiers force people living with or vulnerable to HIV to pay high out-of-pocket costs. For example, for drugs on Tiers 5 & 6, enrollees in Blue Home Bronze 7000 have to pay 50 percent co-insurance (which is 50 percent of the list price of the drug) after a $7,000 deductible for an individual and $14,000 for a family. For those in Blue Home Silver Preferred 3100, the cost-sharing is also 50 percent cost-sharing, but after a $3,100 deductible for an individual and $6,200 for a family.

“The ACA’s non-discrimination provisions are very clear, placing all drugs for a particular condition on a high-cost tier discourages enrollment and is presumptively discriminatory,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “This is a clear effort to dissuade people living with and at risk of HIV from enrolling in these plans and jeopardizes people’s health and the public health since enrollees would be forced to pay huge sums of money just to access their life-saving HIV drugs.”

“We need to make access to HIV drugs as affordable as possible for people living with and vulnerable to HIV in North Carolina,” said Veleria Levy, interim executive director of the North Carolina AIDS Action Network. “Our people already face stigma and other barriers to care and treatment. The ACA is there to protect people from discriminatory insurance company practices. Now we need to make sure the law is enforced, and corrective action is immediately taken to protect the people of North Carolina.”

Failure to address this discriminatory policy will worsen health inequities. Black and African American individuals experience significantly higher rates of new HIV diagnoses than other racial and ethnic groups in North Carolina. Black people make up 58% of new HIV diagnoses in the state, compared to 13.2% and 23.7% for Hispanic/Latinx and White people, respectively. Disparities also exist in PrEP use with Black and African American and Hispanic and Latinx communities far less likely to be on PrEP than White people in North Carolina (65.9% of PrEP users are White, while only 26% and 5.8% are Black and Hispanic/Latinx, respectively).

We urge the North Carolina Department of Insurance and the HHS Office of Civil Rights to act quickly to not only enforce the ACA’s requirements, but to work proactively with all issuers in the state to ensure that people living with and vulnerable to HIV have access to the drugs and services they need.

For a copy of the complaint filed with the North Carolina Insurance Department, click here.

For a copy of the complaint filed with the U.S. HHS Office of Civil Rights, click here.

# # #

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.

The North Carolina AIDS Action Network improves the lives of people living with HIV & AIDS and affected communities through outreach and public education, policy advocacy, and community-building to increase visibility and mutual support of people living with HIV & AIDS throughout our state.

Contact: Jennifer Burke
Christina Adeleke

Pin It on Pinterest

Share This