Cost-sharing

Oregon PDAB comments on HIV drug affordability, copay accumulators, and alternative funding programs

Dec 13, 2024

As the Oregon PDAB begins reviewing its initial list of prescription drugs, we believe that affordability reviews of HIV medications fail to fully account for the intricacies of the existing HIV safety net, which makes lifesaving HIV treatments affordable for most people. We also want to raise numerous factors in the global HIV drug ecosystem that would be difficult for a state to consider. Finally, we reiterate our support for the proposed legislative policy recommendations that enhance transparency around insurers’ use of copay accumulators, maximizers, and the need to consider alternative funding programs.

PACHA comments urging enforcement of ACA non-discriminatory regulations on HIV treatment

Dec 12, 2024

The HIV+Hepatitis Policy Institute again urges the Secretary to take administrative action to ensure that the ACA’s non-discrimination regulations are fully enforced. In the states where CCIIO has jurisdiction, it must investigate complaints and ensure plans are in compliance. In the other states, CMS should update tools to empower states to review plans as they are filed annually to ensure that HIV drugs included in national treatment guidelines are covered, and that HIV drugs are properly tiered. CMS regulations clarifying that these practices are presumptively discriminatory date were first promulgated in 2016, and further updated in 2022, but the tools CMS provides to review the plans do not yet provide adequate protections to ensure that people with HIV are not discouraged from enrollment. Finally, the HHS Office of Civil Rights should be brought to the table in this process to further assess bias and discriminatory review with regard to insurance plans and their coverage of HIV drugs.

Support for Utah “Health Insurance Modifications” so that patients can afford their prescription medications

Nov 19, 2024

We strongly support Utah’s “Health Insurance Modifications,” which would require health insurers to accept and count payments made on behalf of patients towards deductibles and out-of-pocket maximums. We thank you for introducing this bill and look forward to its passage by the Judiciary Interim Committee.

Substandard & discriminatory HIV medication plan design and coverage by Medica in Iowa

Nov 15, 2024

These benefit designs, which discourage enrollment by Iowans living with HIV, are plainly discriminatory. We urge the Iowa Insurance Division, which reviews, approves, and regulates Marketplace plans in Iowa, to take immediate action against Medica for offering these substandard plans that violate the ACA and its implementing regulations. We urge you to ensure that these violations are rectified before the new plan year begins.

HIV+Hep & RIPHI & Open Door Health complaint on substandard & discriminatory HIV medication coverage by Harvard Pilgrim Healthcare in Rhode Island

Nov 8, 2024

HIV+Hep, Rhode Island Public Health Institute, and Open Door Health are writing to express our concern about substandard, discriminatory coverage of HIV treatment medications by Harvard Pilgrim Health Care health plans that use its 2025 “Core 5 Tier” formulary in Rhode Island. These plans do not meet the regulatory standards for formulary adequacy in CFR 156.122 (a)(3)(iii)(H) by failing to cover treatment regimens recommended in broadly accepted treatment guidelines and that are indicative of clinical best practice, thereby discouraging enrollment by people living with HIV.

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