HIV+Hep alleges Texas health plan providing substandard & discriminatory HIV drug coverage

Plan Approved by Federal Regulators Does Not Follow Treatment Guidelines

Washington DC… Today, the HIV+Hepatitis Policy Institute filed another complaint against an insurer for violating the patient protections included in the Affordable Care Act.  This time, the group alleges that Community Health Choice Texas, based in Houston, offers substandard HIV drug coverage by not covering recommended drugs for HIV treatment, including single tablet regimens, and is discriminating against people with HIV by placing most of the drugs that it does cover on the highest and most costly tier.

In its complaint filed with the Center for Consumer Information and Insurance Oversight (CCIIO), HIV+Hep describes the insurer’s drug formulary to be deceptively complete because it lists over 100 HIV drugs. But, in reality, over half are marked as being not covered, and of the drugs that are covered, many are formulations of the same generic drug. Many are no longer prescribed, and some were discontinued by their manufacturer years ago for severe side effects and lack of efficacy.

For example, stavudine, which is on the formulary, was discontinued by its manufacturer after the WHO recommended that it be phased out due to its high toxicity levels. Also included are the first two drugs approved for HIV, zidovudine (AZT) and didanosine (ddI), in 1987 and 1991, respectively, both of which are not prescribed today due to their ineffectiveness and complications.

While the rules implementing the ACA require insurers to include medications that are part of accepted treatment guidelines, one of the Texas plans does not cover a single recommended drug used to initiate therapy that is on NIH’s HIV treatment guideline. Another plan just covers three, but two of them have to be taken as three separate pills.

The insurer does not cover many single tablet regimens and instead requires people to take numerous drug components. This type of treatment is reminiscent of decades ago when people with HIV had to take handfuls of drugs throughout the day. The federal government has said that this type of benefit design is discriminatory against people with HIV.

Last year, the plans did cover the most widely prescribed HIV treatment in the nation, but it was removed for this year, which resulted in people who were stable on their treatment scrambling to stay on their prescribed therapy or seek alternatives.

“Community Health Choice is making a mockery of the ACA rules insurers must follow to develop its drug formulary. How can they and their PBM Navitus state with a straight face that they really used a committee of ‘medical professionals’ that reviewed ‘peer-reviewed journals and treatment guidelines’ to develop its formulary,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute. “To make matters worse, the federal government is charged with reviewing and approving plans in Texas, and they completely missed these obvious deficiencies and, in the process, harmed people with HIV.”

The complaint also details discriminatory plan design since HIV+Hep found that 68 percent of all the covered HIV drugs are on the highest tier, which can translate into 50 percent coinsurance. While some of the HIV drugs were on lower tiers, most of them were substandard or discontinued medications. The federal government has stated that plans that place almost all drugs on the highest tiers are discriminatory.

The HIV+Hepatitis Policy Institute is asking the federal regulator CCIIO to take immediate action against the insurer and to make sure it does not approve similar plans for 2024, which will be released in the next couple of weeks.

HIV+Hep recently 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.

Substandard insurance plans such as this one forestall effective treatment of HIV and jeopardize not only the individual’s health but efforts to suppress the virus, which makes HIV untransmissible. Houston is one of the Phase I communities targeted by the federal government to end HIV due to the high prevalence of HIV in the county, which primarily impacts Black people. Though Black people are 18 percent of Houston’s population, they account for 48 percent of the diagnoses.  There are nearly 30,000 people living with HIV in Houston.  

“We have seen a long-standing practice of some insurers that continue to discriminate against people with HIV in the way they design their benefits. We also continue to hear of people who are using PrEP to prevent HIV being illegally charged by their insurers for this zero cost-sharing preventive service,” added Schmid. “Without strict oversight and enforcement by federal and state regulators, insurers will continue to try to get away with as much as they can. That needs to stop.”

To review the Community Health Choice “Premier” Plan formulary of HIV medications, click here.

To review the Community Health Choice “Select” Plan formulary of HIV medications, click here.

To read the full complaint letter to CCIIO, 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.