HIV Drug Access Limited for Patients in Exchange Plans

Study finds many silver plans have higher out-of-pocket costs for most the commonly prescribed HIV treatments.

Patients with HIV who obtain coverage through health insurance exchange plans face a tougher road to access treatment, the results of a recent study indicate.

An analysis by Avalere Health revealed that just 16% of silver exchange plans cover all of the most frequently used HIV drug regimens in 2015, with cost sharing of less than $100 per month per regimen.

Despite the fact that nearly half of silver plans include the 10 most commonly used HIV drug regimens on their respective formularies, many plans charge higher out-of-pocket costs for the treatments.

“Ensuring individuals living with HIV have affordable access to their medications is critical both for maintaining the health of the patient but also for improving public health by limiting disease transmission,” Avalere Senior Vice President Caroline Pearson said in a press release.

The report noted that access to therapy is influenced by the inclusion of all medications in a regimen on plan formularies, and the out-of-pocket costs for copays or coinsurance.

Comprehensive coverage is of vital importance for patients with HIV due to the unique treatment needs that spring from drug resistance, adverse events, and pill burden, Avalere noted. Furthermore, higher out-of-pocket spending has been found to have a negative impact on medication adherence.

The nationwide analysis showed most plans cover less than 7 of the top therapy regimens and/or charge more than $200 per month for cost sharing in 31 states and the District of Columbia. In contrast, most plans in Alabama, Connecticut, Massachusetts, Oklahoma, and Rhode Island cover all 10 regimens with cost sharing of $100 or less per month.

These regimens include Atripla, Complera, Stribild, Triumeq, Truvada/Prezista, Truvada/Reyataz, Truvada/Isentress, Truvada/Kaletra, Truvada/Tivicay, and Epzicom/Prezista.

The report found that AIDS Drug Assistance Program (ADAP) formularies cover all 10 of the most commonly prescribed HIV drug regimens in 47 of 50 states, while the 3 states not covering all 10 of the regimens (Montana, Rhode Island, and South Dakota) cover 9 out of 10 regimens.

Additionally, the report found that some ADAPs provide wrap-around coverage to decrease patient drug cost sharing in exchanges. HIV drugs accessed through employer provided insurance plans are rarely placed on a specialty tier and are widely covered on generic and preferred brand tiers.

The study found that 51% of silver plans in 2015 did not place any HIV drugs on the specialty tier, while 30% of plans placed all 10 regimens on the highest tier. Triumeq, approved in 2014, was covered by just 50% of plans. Coinsurance was used 52% of the time compared with 48% for copays.

Avalere previously found single source HIV medications face utilization management 8% of the time in employer sponsored plans, and were placed on a specialty tier 3% of the time. Meanwhile, 30% of silver exchange plans have the 10 drug regimens on the highest tier.

“As the 2016 exchange open enrollment period begins, it will be important to assess whether these trends in HIV drug coverage persist to ensure patients who need these drugs enroll in plans with broad access,” Avalere wrote in the report.