ACA complaint filed with Pennsylvania Insurance Commissioner on Highmark Marketplace Plans
Commissioner
Pennsylvania Insurance Department
1326 Strawberry Square
Harrisburg PA 17120
Dear Commissioner Humphreys:
The HIV+Hepatitis Policy Institute is a leading national HIV and hepatitis policy organization promoting quality and affordable healthcare for people and communities affected by HIV, hepatitis, and other serious and chronic health conditions. We are writing to submit a formal complaint regarding plans offered on the Pennsylvania Marketplace by Highmark Inc. Our formulary review has found that Highmark plans offered in the 2026 plan year appear to violate federal Essential Health Benefits (EHB), discrimination, and preventive health coverage requirements in the following ways: (1) use of a copay maximizer; (2) adverse tiering; and (3) non-compliant coverage of preventive health, specifically of HIV pre-exposure prophylaxis (PrEP).
Copay maximizer
Highmark plans appear to employ a copay maximizer program in plans offered on the Pennsylvania Marketplace. Copay maximizers are a benefit design in which a plan structures patient cost-sharing so as to maximize the amount paid by manufacturer copay assistance programs to the plans, without crediting these amounts towards patient deductibles or out-of-pocket maximums. This is usually done by designating a covered medication as a non-Essential Health Benefit in order to bypass ACA cost-sharing protections such as the maximum out-of-pocket. The plan will then impose very high out-of-pocket costs in order to compel enrollees to enroll with their maximizer program vendor, which will ensure that the maximum amount of manufacturer copay assistance is collected and retained by the employer, the plan, and the outside vendor. This harmful benefit design is usually highly opaque to enrollees and threatens the viability of manufacturer cost assistance programs.
The 2025 Notice of Benefit and Payment Parameters rule clarified that all covered drugs in the individual and small group markets must be considered Essential Health Benefits and are therefore subject to ACA cost-sharing requirements.[1] This means that copay maximizers are prohibited on the ACA Marketplaces—unless copay maximizer vendors have found a new loophole to implement this scheme.
We have found that Highmark partners with Pillar Rx to offer a program called “Copay Armor,” which is described in a Highmark document online as a purely voluntary program that “helps to leverage manufacturer assistance dollars to lower your out-of-pocket prescription costs.”[2] However, plan documents suggest the program penalizes members who do not enroll and exemplifies the typical copay maximizer structure.
A 2026 benefits document from an employer plan administered by Highmark states:[3]
The Copay Armor program helps members to afford high cost medications (mostly specialty) by leveraging manufacturer coupon dollars. Members will not need to change where prescriptions are filled and will be contacted by Pillar Rx for cost savings enrollment. If eligible members do not enroll in this money saving program at no additional cost, then a new 30% coinsurance will apply to certain high cost medications.
Our analysis of Highmark’s online formulary for Pennsylvania Marketplace plans[4] reveals that 689 drug formulations out of approximately 9,300 total, or 7 percent, require the use of Copay Armor. These 689 drug formulations refer to different dosages and administration types for 269 unique drugs.[5] As illustrated in the chart below, we found that the drug classes with the highest percent of unique drugs which are designated Copay Armor drugs are multiple sclerosis agents (20 or 57.1% of 35 unique drugs), hematological agents (42 or 32.6% of 129 unique drugs), antineoplastics (56 or 28.9% of 194 unique drugs), metabolic modifiers (7 or 18.4% of 38 unique drugs), hepatobiliary system treatment agents (1 or 14.3% of 7 unique drugs), and anti-infective agents (33 or 12.4% of 267 unique drugs).
HIV treatment drugs are heavily represented on the Copay Armor list, with 15 or 36.6% of 41 unique antiretroviral drugs listed in the plan formulary but only available through Copay Armor. Notably, Highmark is requiring patients to enroll in the maximizer program to access drugs that are recommended in national treatment guidelines for HIV treatment, drugs that Highmark should be covering:
- Of the four “preferred” first-line regimens recommended in current HIV treatment guidelines for most people (Biktarvy, Dovato, Symtuza, and the combination of Tivicay with either Truvada or Descovy), not one is available without going through Copay Armor.
- Of the four “alternative” first-line regimens recommended for use in certain clinical scenarios, only two are available without going through Copay Armor.
- Of the thirteen commercially available single-tablet regimens, only three are available without going through Copay Armor: Triumeq, Atripla, and Symfi (Lo)—the last two of which are low-cost generic efavirenz-based regimens, which are no longer the standard of care in part due to unfavorable neuropsychiatric side effects.
Hepatitis C drugs have an even higher rate of Copay Armor coverage, with 5 out of 10 unique drugs (50%) listed as Copay Armor program drugs.
We would note that 430 or 63% of the drug formulations with a Copay Armor designation are listed as “NF” or “non-formulary.” We assume that a patient on one of these medications must surmount two barriers: first they must seek an exception through the step therapy program, after which they will need to resort to Copay Armor for presumably very high cost-sharing paid by manufacturer assistance.
We urge the Pennsylvania Insurance Department to determine if Highmark is impermissibly designating covered drugs as non-EHB in Marketplace and other state-regulated plans:
- Does manufacturer copay assistance for Copay Armor drugs apply towards enrollee deductibles and out-of-pocket maximums in compliance with the law?
- Is Highmark collecting an amount of cost-sharing greater than is legally allowed?
- How are Copay Armor program drugs being considered and calculated when the plan determines actuarial value and MLR?
- Does the calculation for the actuarial value of Highmark’s plans correctly account for Copay Armor non-formulary drugs approved for coverage after an exceptions process?
- How is cost-sharing set for Copay Armor enrollees? How is cost-sharing set for Copay Armor enrollees after copay assistance has been exhausted? How is cost-sharing set for those who choose not to enroll in Copay Armor? Is the tier listed in the formulary followed? What cost-sharing is applied to non-formulary drugs when approved for coverage?
- Are enrollees in Highmark plans adequately informed of Copay Armor program? Is it included in the Summary of Benefits and Coverage or in the plan brochure? Is the cost-sharing benefit design adequately explained?
- Are enrollees in Highmark plans informed whether manufacturer assistance counts towards deductibles and out-of-pocket maximums?
Adverse tiering
In our review of Highmark’s formularies, we found that the issuer also engages in adverse tiering of antiretrovirals. Adverse tiering is a prohibited benefit design in which all or the majority of drugs to treat a particular health condition are placed on the highest cost-sharing tiers. Adverse tiering is an example of discriminatory formulary design. Under ACA rules, formularies may not discourage enrollment by any group of enrollees, and must provide appropriate access to drugs included in broadly accepted treatment guidelines and that are indicative of general best practices at the time.[6] Adverse tiering has been recognized as presumptively discriminatory by CMS since 2015.[7]
Highmark clearly discourages enrollment by people with HIV in its My Blue Access PPO Bronze 3800 plan.[8] In this plan, Tier 1 drugs are associated with modest $15 copays, while the drugs in the remaining Tiers 2, 3, and 4 are subject to 50% coinsurance. Critically, all antiretrovirals—even low-cost generics—are covered on either Tier 2 (5 out of 42 drugs) or Tier 3 (37 out of 42 drugs), while no antiretrovirals drugs are on the low-cost tier. There can be no doubt that this tiering structure is in clear violation of long-standing protections against discriminatory formulary design.
It is important to note that the practice of adverse tiering is assessed at the plan level, not the issuer level,[9] so Highmark should not be able to point to the availability of plans for which antiretroviral drugs are not on the highest cost tier to justify the existence of other plans which do engage in this discriminatory practice.
PrEP coverage
In March 2026, Highmark placed an oral PrEP drug (Descovy) on a non-preventive tier, failing to comply with current ACA rules that mandate that all PrEP drugs be covered without cost-sharing.[10] Within a week of our noting this non-compliant coverage at a meeting at the National Association of Insurance Commissioners, Highmark changed their online formulary and correctly listed the drug as available on the preventive no-cost tier.
We would note that it is difficult for beneficiaries to determine if issuers are meeting coverage requirements for long-acting injectable PrEP drugs such as Apretude or Yeztugo when they are available only through the medical benefit. When we called Highmark to determine if injectable PrEP drugs were covered without cost-sharing or prior authorization, we twice received ambiguous answers from call center staff. We were unable to determine if a prior authorization was required for Apretude, and we were unable to determine if Yeztugo was covered through the medical benefit, with one customer service representative saying, “If you want to know if it is available on the medical benefit, a doctor will have to prescribe it,” leading us to question if Highmark coverage of these drugs meets ACA requirements.
In conclusion, we urge PID to continue to protect Pennsylvanians affected by HIV—and all Pennsylvanians—from these apparently illegal benefit designs. We look forward to learning what actions you will take regarding Highmark’s formulary in order to ensure that all 2026 Marketplace and other state-regulated plans are in compliance with ACA coverage requirements.
If you have any questions, comments, or would like to discuss these issues further, please contact Carl Schmid, Executive Director, HIV+Hepatitis Policy Institute at cschmid@hivhep.org or (202) 462-3042; or Kevin Herwig, Health Policy Manager, HIV+Hepatitis Policy Institute at kherwig@hivhep.org or (617) 666-6634.
Sincerely,
Carl E. Schmid, II
Executive Director
cc: David Buono, Deputy Commissioner, Market Regulation, PID
Peter Nelson, Director, CCIIO
Jeff Wu, Deputy Director for Policy, CCIIO
Paula M. Stannard, Director, HHS Office for Civil Rights
Heather Hauck, Associate Administrator, HIV/AIDS Bureau, HRSA
[1] 45 CFR 156.122 (f)
[2] https://wcho.gobenefits.net/wp-content/uploads/2022/08/Highmark-Copay-Armor-Specialty-Drug-Program.pdf
[3] https://services2.juniata.edu/hr/docs/2026PPOGoldPlanGrid.pdf (accessed April 2026)
[4] https://client.formularynavigator.com/Search.aspx?siteCode=6571849149 (accessed April 2026). This formulary is also used in Delaware and West Virginia. It is also available in a pdf format that, as of April 2026, employs a null character for Copay Armor drugs, rendering this aspect of coverage invisible to enrollees: https://fm.formularynavigator.com/FBO/9/HCR_Essential_Closed_State_Exchange_2018_Standard.pdf.
[5] Brands and their corresponding generic are counted as two drugs.
[6] 45 CFR 156.122(a)(3)(iii)(H); 45 CFR 156.225(b)
[7] See, for example, the 2016 Payment Notice Final Rule (80 FR 10822)
[8] https://shop.highmark.com/content/sbcs/2026/CPA/Individual/I_33709PA1480001-01_20260101_SBC.pdf (accessed April 2026)
[9] For example, CMS states in the 2025 Letter to Issuers that “[p]lans will be flagged for possible adverse tiering if all drugs for at least one of the four medical conditions are placed on the highest effective cost sharing tier,” https://www.cms.gov/files/document/final-2026-letter-issuers.pdf.
[10] https://www.cms.gov/files/document/faqs-implementation-part-68.pdf