Most Texas exchange plans limit access to HIV drugs

HIV-positive people shopping on the federal health insurance exchange in Texas will find that most plans tightly restrict access to HIV drugs, a strategy advocates say is designed to keep infected patients from choosing those plans.

According to an analysis by Avalere Health, most silver exchange plans offered in Texas in 2015 covered fewer than seven of the 10 most common HIV treatment regimens or required cost sharing of more than $200 per month. Silver plans, one of four tiers of coverage offered on the exchange, cover about 70 percent of the cost of care, leaving 30 percent to the patient. But patients must sign up for silver plans in order to get subsidies that lower the cost of monthly premiums and co-pays.

HIV-positive patients often are highly dependent on their specific combination of HIV drugs due to factors such as side effects or drug resistance.

"Ensuring individuals 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," said Caroline Pearson, senior vice president at Avalere and the author of the report.

Texas, 30 other states and the District of Columbia fell into the most restrictive category. In seven states, most plans covered between 7 and 9 of the 10 most common treatments, while in another seven states, plans were evenly distributed among those with good, moderate and poor access.

Most plans granted full access only in five states: Alaska, Connecticut, Massachusetts, Oklahoma and Rhode Island.

The restrictive access to HIV drugs appears to be limited primarily to exchange plans. Avalere previously found that HIV drugs were widely covered by employer-sponsored health plans. Only 3 percent of employer-sponsored plans placed HIV medications into the specialty tier that required significantly larger copays, while 30 percent of exchange plans nationwide placed 10 treatment regimens in the highest tier.

Last year, The AIDS Institute and National Health Law Program filed a complaint with the Office of Civil Rights at the U.S. Department of Health and Human Services alleging four insurers in Florida were violating the Affordable Care Act. The complaint said the insurers designed plans that discouraged HIV patients from signing up by making it difficult for patients to get their medications. The plans ultimately agreed to make HIV drugs in those plans more accessible.

Legacy Community Health, a federally qualified health center in Houston that treats many HIV patients, holds educational sessions to help patients evaluate the drug coverage and cost sharing of various exchange plans. According to Melissa Garcia, senior director of patient billing for Legacy, many plans change the medications they cover from year to year and shift drugs from one tier to another.

"That is something that people don't think about -- this plan worked great for you last year, so I don't have to do anything, I just keep going," she said. "They get into it and what cost them $20 last year, might cost $150 this year. It's no different from a patient who needs a diabetes medication all the time, you've got to keep checking it to make sure."