The largest insurer in North Carolina recently lowered the out-of-pocket cost of its HIV drugs, including PrEP, after complaints from advocacy organizations to the state and federal governments.
The HIV+Hepatitis Policy Institute and the North Carolina AIDS Action Network filed the complaints last year with the North Carolina Department of Insurance and the Office of Civil Rights at the U.S. Department of Health and Human Services against Blue Cross and Blue Shield of North Carolina.
The basis for the complaints was the Patient Protection and Affordable Care Act's patient protections, which extends the non-discrimination protections of the Civil Rights Act of 1964 — which expressly includes disability — to "any health program or activity, any part of which is receiving Federal financial assistance, including credits, subsidies, or contracts of insurance."
"Section 1557 of the ACA explicitly prohibits health plan designs that discriminate on the basis of disability," the complaint to the HHS Office of Civil Rights stated. "Under existing case law, even asymptomatic people with HIV are considered disabled and protected under federal anti-discrimination laws."
The complaint alleged that Blue Cross and Blue Shield of North Carolina were putting most HIV treatment and preventative drugs on the highest two tiers of the company's six tiers of cost sharing. These tiers are reserved for the "highest-cost prescription medications," the company stated.
The only HIV drugs on lower tiers were generic, and had to be taken in conjunction with other medications.
"Drugs placed on the highest tiers force people living with or vulnerable to HIV to pay high out-of-pocket costs," the two HIV advocacy groups stated in a news release. "For example, for drugs on Tiers 5 & 6, enrollees in Blue Home Bronze 7000 have to pay 50% co-insurance (which is 50% of the list price of the drug) after a $7,000 deductible for an individual and $14,000 for a family. For those in Blue Home Silver Preferred 3100, the cost-sharing is also 50% cost-sharing, but after a $3,100 deductible for an individual and $6,200 for a family."
These included the drugs used for PrEP, or pre-exposure prophylaxis, which refers to the use of antiviral drugs to prevent people exposed to HIV from becoming infected. The pill Truvada was first approved for PrEP use in 2012 by the federal Food and Drug Administration; since then the FDA has also approved the pill Descovy for some groups, and the drug Apretude as an injectable treatment. According to federal Centers for Disease Control and Prevention statistics, only 25% of the approximately 1.2 million Americans who could benefit from PrEP had prescriptions in 2020.
Last month, however, Blue Cross and Blue Shield of North Carolina changed tact. Now, no HIV drugs are in the top highest tiers.
Nineteen HIV drugs on tiers four, five, and six have been moved to the second tier, which is lower in cost.
Carl Schmid, a gay man who is the executive director of the HIV+Hepatitis Policy Institute, stated, "insurers seem to try to get away with as much as they can until they are caught."
"While pleased to see this dramatic turnaround by the insurer, blatant discriminatory plan design and violation of the ACA's patient protections should not happen in the first place," Schmid stated. "For insurance to work for patients, we need better federal and state regulation, oversight, and enforcement. A drug formulary with adverse tiering should never be approved. As insurers across the country are now submitting their plans for 2024, consumers must be assured that drug formularies are being carefully reviewed to protect all beneficiaries, not just those living with HIV."
The North Carolina AIDS Action Network joined in the complaints. Veleria Levy, its executive director, called the changes "a victory for people living with HIV in North Carolina."
"Our people already face stigma and other barriers to care and treatment," Levy stated.
"While we are disappointed that it took a formal discrimination complaint and this practice went on for years, we are pleased to see that the ACA patient protections work, and people are protected from discriminatory insurance company practices. North Carolina BCBS still has plans that charge beneficiaries 50% cost-sharing for all but tier one drugs, so it is important for people to select the plan that best meets their needs to take advantage of these plan changes."
The advocacy groups claim that they never received any communication from the federal or state governments that the complaints they'd brought had been acted upon.
Neither the Tar Heel State's insurance department nor the federal HHS returned requests for comment for this report as of press time.
A phone operator with Blue Cross and Blue Shield of North Carolina sent a reporter inquiring to contact the company to a phone line that required a patient ID to continue.
LGBTQ Agenda is an online column that appears weekly. Got a tip on queer news? Contact John Ferrannini at [email protected]
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