Aetna is changing the drug benefits in all of its individual health plans effective June 1, lowering the patient costs for HIV drugs.
The announcement comes in the wake of concerns from researchers and consumer groups that many insurers are pricing people with serious, costly health issues out of health plans by making critical medications too expensive.
The National Health Law Program filed a federal complaint alleging insurers engaged in the practice called “adverse tiering” in Florida last year. The federal government has issued guidelines discouraging the practice.
“It does no good to get the insurance if, once you get the insurance, you can’t afford the prescription drugs that are provided under the plan, ” said NHLP director Elizabeth Taylor.
Before the Affordable Care Act, insurance companies could — and did — deny coverage to people who were sick or charge them a lot more. The ACA bans both of these practices, but Taylor and others worry insurers have found a work-around through adverse tiering and having patients with chronic health conditions shoulder a greater portion of the cost of their needed drugs.
She’s also concerned that if one company engages in this practice, others will follow suit because it’s too expensive for one company to cover everyone with HIV or another health issue.
An Aetna representative said in an email that the company made the decision voluntarily after re-evaluating its health plans, and that lowering beneficiaries’ costs stemmed from the company’s goal of delivering the best value to members. The changes will specifically lower co-pays to between $5 and $100 a month, depending on the HIV drug.
“This is definitely a step in the right direction and realizing what the Affordable Care Act promises,” said Taylor, in response to Aetna’s announcement.
Consumer advocates in Pennsylvania point to the state’s robust financial assistance program for people who can’t afford their HIV meds, but they hope Aetna’s decision sets the tone when companies design drug benefits for other serious conditions, such as diabetes, asthma or mental illness.
“I think what we’ve seen, with this Aetna change with medications and with CMS [the Center for Medicare and Medicaid Services] paying more attention to this issue, is really positive,” said Suzanne Cohen with the Health Federation of Philadelphia. “It’s saying, you can’t discriminate against these people by charging a huge amount of money for the drugs that they need to stay healthy.”
Cohen has been following HIV drug benefits offered through the federal marketplace in Pennsylvania. She said Aetna’s plan did stand out compared with others for its high HIV drug costs, though she has not heard of any patients encountering problems accessing the needed medications.