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Policy Guide

Health Insurance Marketplace Plans and People Living With HIV and/or Viral Hepatitis: The Success of the Affordable Care Act Requires Fair Drug Pricing and Access

February 2014

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Following are immediate measures and long-term solutions that would ease the burdens of these current and anticipated barriers to affordable HIV and/or HCV treatment:

  1. Require access to all HHS-preferred and HHS-alternative antiretrovirals for HIV and FDA-approved treatments for HCV. The FPC and its partners have confirmed that some QHPs are not covering some standard-of-care HIV medications, including single tablet regimens that may promote adherence and decrease OOP cost barriers.
  2. Monitor tiering of HIV and HCV drugs for discriminatory practices, such as placing all recommended treatment options on the highest cost-sharing or specialty tiers. QHPs should be required to make standard-of-care drugs for HIV and HCV available at lower cost-sharing tiers if there are no generic equivalents available.
  3. Mandate QHP benefits and drug formulary transparency. People living with HIV and/or HCV require access to comprehensive and clear information regarding the specific benefits -- including health care provider participation, specialty care, social/ancillary services, laboratory tests and imaging, drug formularies, and cost-sharing obligations, as well as co-payment or co-insurance tiers (including precise OOP cost details) -- of QHPs participating in state or federal health insurance marketplaces to determine which plans best meet their needs. This information is also required by Ryan White Part B and other programs, as well as AIDS Drug Assistance Programs (ADAPs) providing QHP premium and OOP assistance.
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  5. Confirm Secretary Sebelius' indication that manufacturers and non-profit payers may help defray OOP costs for medications under ACA. This is especially important where there is no generic equivalent. A model for this exists in Massachusetts, which passed analogous provisions last year (Mass. Gen. Laws ch. 175H, sec. 3). This principle should also extend to Medicare Part D beneficiaries.
  6. Lower the OOP spending caps. As defined by the Commonwealth Fund, a foundation focusing on health care access and reform, individuals within 200 and 250 percent of the federal poverty level facing OOP expenditures greater than 5 or 10 percent of their annual incomes, respectively, are underinsured. A single man living with HIV earning $24,000 a year -- slightly more than 200 percent of the federal poverty level -- may ultimately be billed $5,200 in expenses, or roughly 22 percent of his income, with much of that coming at the front end of his coverage period. Should the QHP practice of placing critical HIV and HCV drugs on high co-payment or co-insurance tiers continue, substantially reduced caps will be essential. Also, as is being explored in California, monthly OOP expense associated with prescription drugs should be limited to one-twelfth of the full OOP cap.
  7. Include HIV and HCV diagnoses as qualifying life events for new enrollment in, or a switch to, a QHP offering comprehensive and affordable care and treatment. To achieve National HIV/AIDS Strategy and Viral Hepatitis Action Plan goals to maximize linkage to care, retention in care and access to treatment, prompt enrollment in a QHP that adequately and affordably covers comprehensive care and prescription drugs is essential.
  8. Disclose pricing practices. Manufacturers should disclose the costs of research and development, manufacturing, marketing, and offsetting contributions, such as outside research. This information is essential to efforts promoting fair pricing, rebates and discounts, and public knowledge of the returns on investments required to promote innovation and competition.
  9. Insurance companies must ensure there is HIV and HCV expertise on their pharmacy and therapeutics committees or that they consult disease experts regarding formulary and tiering decisions. It is currently unclear how formulary decisions are made by plans and/or whether there is sufficient consultation of experts in particular diseases such as HIV and HCV. Given the extreme range of QHP formulary coverage and pricing decisions, more scrutiny -- and transparency -- of this process is warranted.

These problems are not insurmountable. The FPC believes that the Affordable Care Act, while not perfect, has tremendous potential to redress disparities for U.S. residents whose access to healthcare has previously been at the whim of conflicting political and economic forces. This applies not only to HIV/AIDS and viral hepatitis, but also to many other chronic, debilitating, and costly health challenges beyond the capacity of individuals to manage on their own. The FPC supports urgent attention to these matters for all Americans at this moment of new hope for achieving universal, affordable, quality health care.


  1. Families may be required to pay up to $12,700 in OOP costs. The cap on OOP costs will be lower for families with incomes up to 250 percent FPL ($49,475 for a family of three).
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This article was provided by Fair Pricing Coalition. Visit FPC's website to find out more about their activities and publications.
See Also
More U.S. HIV Treatment Policy Analysis


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