State tells insurers to limit co-pays for HIV/AIDS drugs

July 01--Supporters of civil rights for people living in Florida with HIV/AIDS are applauding the state Office of Insurance Regulation for warning insurance companies not to overcharge patients for drugs in their 2016 federal marketplace plans.

The notice, by Florida's Office of Insurance Regulation, follows complaints last year by the Tampa-based AIDS Institute and National Health Law Program claiming that four health insurance companies were illegally grouping up to 30 AIDS treatment drugs into the highest and most-expensive co-insurance payment tier.

Florida's notice, sent to insurers in the spring, advised companies to be ready to explain why their pricing of HIV/AIDS medications is not "unfairly discriminatory" when they submit their 2016 health plan rates for state review. Discriminatory pricing, the notice said, could result in a recommendation for the plan's removal and decertification from the Federal Health Insurance Marketplace.

"Florida's law is unique in that it specifically prohibits limiting coverage for individuals with HIV or a specific medical condition resulting from HIV such as AIDS," said Amy Bogner, spokeswoman for the Office of Insurance Regulation, in an email.

Florida had 108,608 people living with HIV/AIDS at the end of April, according to the state Department of Health. Of those, 26,678 were in Broward and Palm Beach counties and 27,899 were in Miami-Dade.

According to the complaint filed with the federal Department of Health and Human Services by the AIDS Institute and National Health Law Program in May 2014, four insurers -- Aetna, Humana, Cigna and Preferred Medical -- were placing drugs HIV and AIDS on high-percentage co-pay tiers that resulted in some patients paying as much as $1,000 a month.

By making those drugs so expensive, the companies were discouraging people with HIV/AIDS from enrolling in those plans and driving them to other plans that limited co-pays for the drugs to $70 or less, said Carl Schmid, deputy executive director of the AIDS Institute.

"I assume most patients went to other plans," Schmid said in an interview. "That's what we didn't want to happen. That's not fair to those plans" without the high co-pays.

The letter from Florida's insurance regulator to insurers outlined the benchmark plan that limits patient co-pays to between $40 and $150 for a month-long supply, except for an inject able drug with a $200 co-pay. A plan's drug pricing formula will be considered compliant if it's at least "as favorable as the state's benchmark plan," the letter to insurers stated.

In March, Aetna agreed to reduce co-pays for non-inject able drugs to no more than $100 after deductibles are met. Previously, Cigna entered a consent order with Florida regulators agreeing to move generic HIV drugs to a lower-cost tier and cap co-payments for four other drugs at $200 a month in 2015.

Humana and Preferred Medical entered into similar agreements with the state as well.

The AIDS Institute's Schmid said the Florida letter is important for two reasons. One is the state's intention to review plans for how they price all drugs, and not just HIV/AIDS drugs. Health plans are also charging high co-pays for drugs that cover a number of chronic illnesses, including cancer, rheumatoid arthritis and mental illness, he said.

Another reason is the letter cites the specific state law barring discrimination against patients who need HIV/AIDS drugs.

Bogner, the Office of Insurance Regulation spokeswoman, said that state law only protects discrimination against HIV/AIDS patients but that federal ACA regulations require states to look at pricing of all classes of drugs.

"This is big news for Florida," Schmid said. "Good news for anyone living with HIV in Florida and good news for anyone on medication in Florida."

rhurtibise@sun-sentinel.com, 954-856-5364

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