Dive Brief:
- A new analysis from Avalere Health concluded just 16% of silver plans in the 2015 marketplaces covered all of the 10 major HIV drugs with patient cost sharing under $100 per month per regimen.
- Nearly half of the plans did include all 10 regimens on their formularies, but many of them charged patients higher out-of-pocket costs, Avalere found.
- The availability of marketplace plans that include broad access to HIV treatments varies significantly by state, Avalere noted.
Dive Insight:
Coverage for HIV drugs appears to be unusually varied, resulting in some plan designs that advocates call discriminatory.
“Typically plans have a relatively unified formulary state to state, but HIV is the exception,” Caroline Pearson, a senior vice president at Avalere, was quoted by Kaiser Health News. “If you happen to be in a state that covers them well, you’re well off.”
Pearson suggests the same issues are expected to remain for 2016. “Consumers need to be thoughtful about plan selection," she said.
Those seeking HIV drug coverage under employer-based plans appear to fare better. In that market, "HIV drugs are widely covered on generic and preferred brand tiers and are almost never placed on a specialty tier," Avalere stated. It adds HIV medications were placed on the specialty tier just 3% of the time by employer sponsored plans, while 30% of silver exchange plans placed all 10 treatment regimens on the highest tier.