We commend the Colorado Division of Insurance for taking the initiative to update state guidance on PrEP coverage. We support a finalized regulation and bulletin that clarifies that all PrEP medications and services must be covered without prior authorization or cost-sharing. We urge you to clarify that all FDA-approved PrEP medications must be covered without prior authorization or cost-sharing.
By passing Senate Bill 17, New Hampshire will join 21 other states, the District of Columbia, and Puerto Rico in protecting consumers purchasing insurance on the private market. This legislation ensures that copay assistance counts toward cost-sharing obligations, preventing patients from facing insurmountable financial barriers to their medications.
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.
More and more insurers and PBMs have instituted harmful policies that do not apply copay assistance towards beneficiaries’ out-of-pocket costs and deductibles. Currently, 2 out of 6 health plans available on the New Jersey individual marketplace have language in their individual health plan documents stating that copay assistance may not be counted. When implementing these policies, the insurer collects the copay assistance from the drug manufacturer and the patient is able to pick up their medication, but that copay assistance is not counting towards the beneficiary’s deductible or out-of-pocket obligation. Then, later in the year, when the beneficiary goes to pick up their drug, they find out that copay assistance did not count and are stuck with a huge, unexpected copay. In order to pick up their drug they are forced to come up with often thousands of dollars, which few people have. Insurers are double dipping: first they receive the copay assistance from the drug manufacturer and then they collect it again from the beneficiary.
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.