Updated MN Letter on Medica’s substandard & discriminatory HIV medication plan design and coverage
Commissioner
Minnesota Department of Commerce
85 7th Place East, Suite 280
Saint Paul MN 55101
Dear Commissioner Arnold:
In November 2024, the HIV+Hepatitis Policy Institute submitted a complaint regarding substandard, discriminatory coverage of HIV treatment medications by Medica health plans in Minnesota. We are disappointed that we have yet to receive a response from your Department. We would hope that consumer complaints are promptly acted upon, responded to, and appropriate actions are taken against insurers that violate the law in order to protect consumers.
Now that Medica’s formularies for the 2026 plan year are available we would like to provide an update. We are pleased to note substantial improvements in Medica’s coverage and trust that our complaints in Minnesota and Iowa against Medica played a major role in these improvements. We know that the Iowa Commissioner worked with Medica and hope that you did as well. Despite these improvements, substantial issues remain with Medica’s coverage and tiering of HIV medications and we are submitting additional data comparing Medica’s benefit designs with those of other issuers on the Minnesota Marketplace.
We still maintain that Medica’s benefit designs discourage enrollment by people with HIV, in violation of the non-discrimination provisions of the ACA by (1) not meeting clinical appropriateness standards and (2) engaging in adverse tiering.[1]
(1) Clinical appropriateness.
Complaint: Medica’s plans fail to cover treatment regimens recommended in broadly accepted treatment guidelines and that are indicative of clinical best practice.
Plans must cover drugs recommended in broadly accepted treatment guidelines and reflect clinical best practice, and so should cover all “preferred” and “alternative” first-line regimens as well as other guideline-recommended drugs.
There is n question that Medica’s coverage of HIV treatment has improved substantially in the 2026 plan year. It now covers five out of eight recommended “preferred” and “alternative” first-line treatment regimens, up from three in the 2025 plan year. It has dramatically improved coverage of single-tablet regimens (STRs), covering ten out of twelve in 2026, where it only covered three in 2025. The total number of antiretroviral medications covered has also improved, from 31 out of 53 in 2025 to 34 in 2026.
But the table below demonstrates that Medica remains an outlier in coverage of HIV treatment. Every other issuer on the Minnesota Marketplace covers all eight first-line regimens, every other issuer covers a significantly higher number of all antiretrovirals (ARVs), and every other issuer other than Quartz (available only in a handful of counties) offers coverage of more STRs:
We believe this data demonstrates that Medica has some way to go before it can be deemed to provide clinically appropriate coverage of recommended HIV treatment medications such that it does not discourage enrollment by people with HIV.
(2) Adverse tiering.
Complaint: Medica’s plans engage in a practice known as “adverse tiering,” in which all or the majority of drugs to treat a particular health condition are placed on the highest cost-sharing tiers.
Adverse tiering has been clearly and consistently defined by CMS since 2015: it occurs when an issuer places all or a majority of drugs to treat a particular health condition on a high-cost formulary tier.[2] There can be no doubt that most of Medica’s plans on MNsure violated this straightforward standard in 2025, when it placed 26 (83.9%) of the 31 ARVs it covered on tier 5, (the specialty tier), with only 5 on a low-cost tier.
For the 2026 plan year, Medica has placed 24 (70.6%) of the 34 covered ARVs on tier 5, with 5 ARVs on Tier 4 (non-preferred drugs) and 5 on low-cost tiers, showing that Medica continues to place a majority of HIV treatment drugs on the highest cost-sharing tier despite the tiering changes in the new plan year.
Comparing Medica’s tiering of ARVs to that of other issuers on MNsure, we note that Medica’s tiering, while improved, continues to place a higher percentage of ARVs on the highest-cost tier than any other issuer, with UCare and Medica offering dramatically worse tiering from the other three issuers on the Marketplace:[3]
Since Medica made significant changes to ARV tiering in its 2026 formulary, and since this new formulary passed the QHP review process after the Department of Commerce received our complaint, we compared the tiering of two important subsets of ARVs: STRs and recommended “preferred” and alternative first-line regimens.
Medica and UCare tiering of these two important groups of ARVs once again is sharply divergent from the other three issuers, none of which place a single STR or first-line regimen on the highest-cost tier. We note that Medica has placed five STRs that were not covered on its 2025 formulary on the second highest-cost tier, tier 4 (Odefsey, Triumeq, Complera, Genvoya, and Stribild), suggesting that Medica may have focused its pattern of improvements in tiering exclusively on STRs, and ignored the many important treatment regimens available only as combinations of other medications.
We find that there are other examples of discriminatory tiering of HIV treatments by Medica as well as other issuers:
- Medica offers many plans in which tier 4 is associated with 50% coinsurance while tier 5 is associated with 60% coinsurance. While there is a difference between these two tiers, we believe covering all antiretrovirals on two very high-cost coinsurance tiers still constitutes adverse tiering. [4]
- All issuers on MNsure offer “Easy Compare” plans, which charge a $25 copay for generics, but 50% coinsurance for all medications on the preferred, non-preferred, and specialty tiers.[5] We believe all of these plans engage in adverse tiering since they place all ARVs, STRs, and first-line regimens on tiers that result in high cost-sharing.
Though the pattern of improvement in Medica’s coverage and tiering in 2026 plans is welcome, we believe the data we have presented unequivocally demonstrate that Medica is continuing to provide discriminatory and substandard coverage of HIV treatment medications in ways which discourage the enrollment of people living with HIV. In addition, they show that Medica’s practices are an outlier on the Minnesota Exchange with respect to both adverse tiering and clinical appropriateness.
While we are unaware of any actions you have taken against Medica, we are pleased to see the improvements in its 2026 formularies. These formularies that discriminate against people living with HIV should not happen in the first place and should not have to be corrected through complaints. Despite these improvements we ask you to enforce the law and to examine these continuing problems with Medica and other issuers so that all 2026 Marketplace and other state-regulated plans in Minnesota meet ACA requirements for non-discriminatory coverage of HIV treatment.
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: 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 (a)(3)(iii)(H).
[2] See, for example, the 2016 Payment Notice Final Rule (80 FR 10822): https://www.federalregister.gov/documents/2015/02/27/2015-03751/patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2016
[3] Medica’s recent acquisition of UCare means Medica’s benefit design will soon sharply diverge from that of all other issuers.
[4] Bold by M Health Fairview Gold $0 Copay PCP Visit, North Memorial Acclaim by Medica Silver Copay (First 3), and Medica Applause Bronze Share Plus Metro, to identify just a few.
[5] For example, Blue Cross Blue Shield of Minnesota Blue Plus Easy Compare Bronze Blue Plus Minnesota Value Plan 408, Health Partners Easy Compare Bronze Peak HSA, Medica Easy Compare Bronze North Memorial Acclaim, Quartz Easy Compare Bronze Vision Select, UCare Easy Compare Bronze Plan.