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High cost of drugs price HIV and AIDS patients out of health insurance policies

Insurers blame manufacturers; AHIP's Karen Ignagni says soaring prices threaten entire healthcare system

Advocates have accused some insurers of discouraging HIV and AIDS patients from obtaining coverage under the Affordable Care Act by levying high co-insurance charges for the expensive drugs used to treat the disease and the virus that causes it, the Associated Press reported.

Patients with HIV or AIDS and other serious, chronic diseases can't be denied coverage under healthcare reform, but advocates argue co-insurance as high as 50 percent effectively prices them out of the market.

Insurers blame manufacturers who charge high prices for their drugs. And previous research from Express Scripts found that new enrollees in state and federal insurance marketplaces were more likely to use specialty medications than enrollees in commercial health plans, putting further pressure on payers.

Karen Ignagni, president and CEO of America's Health Insurance Plans, wrote an op-ed in the Wall Street Journal this week, saying that the "soaring prices of some specialty drugs" are threatening the sustainability of the healthcare system.

The AIDS Institute filed a complaint in Florida with the Department of Health and Human Services this summer alleging Humana, CoventryOne, Cigna and Preferred Medical are violating the ACA by requiring steep co-insurance payments for HIV drugs, according to the AP report.

Advocates in Ohio, California, Illinois and Georgia reported similar concerns with Obamacare plans in their states.

Anthem Blue Cross Blue Shield, Coventry, Humana and Medical Mutual were criticized by Ohio AIDS advocates for putting both brand-name and generic HIV drugs in the highest, most-expensive drug tiers or classifying them as specialty drugs, according to the AP. Similarly, in Illinois, Aetna, Coventry, Health Alliance and Humana were criticized by the AIDS Foundation of Chicago for putting most HIV medications in the highest drug tier.

Kaiser Permanente Georgia issued a statement to the AP saying it helps fund organizations that help pay for HIV/AIDS drugs and understands "the burden that high-priced pharmaceuticals can place on patients."

Other insurers responded after the Florida complaint was filed, Kaiser Health News reported at the time.

"The Coventry formularies meet ACA requirements and provide access to drugs necessary for treatment under the current clinical guidelines," Cynthia Michener, a spokesperson for Aetna, Coventry Health Care's parent company, said in a statement.

A Preferred Medical spokesperson said the insurer's HIV medication coverage "meets the requirements for coverage established by federal guidelines," according to KHN.

The issue extends beyond private insurance, Ignagni wrote in the WSJ

"These prices present a systemic challenge. States are having to choose between paying for specialty drugs in Medicaid and paying for education. Medicare Part D could go from a fiscal success--having kept spending under projections--to a program with exploding costs."

For more information:
- read the AP article
- here's the KHN article
- read the WSJ op-ed

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Specialty drug use high among exchange enrollees
UnitedHealth to lift mail-order requirement for HIV/AIDS meds
Apply value-based design to reduce specialty med costs