Pre-reform underwriting approaches for speciality medications like HIV/AIDS drugs are not going to fly in the new health insurance market, as regulators and patient advocates intervene to challenge a range of practices.
In Florida, Insurance Commissioner Kevin McCarty has secured an agreement with Cigna, after complaints that the insurer's public exchange plans placed onerous requirements on access to such medications.
Similar to some other insurers, Cigna's five exchange plans in Florida set HIV/AIDS medications, including generic antiretrovirals, in the highest formulary tier, with prior authorizations, 40 percent coinsurance, and "unnecessary and discriminatory step protocols," according to McCarty's office.
Cigna has maintained that the step requirements and prior authorization were due to the drugs' nature as speciality medications and complied with state and federal law, but nonetheless agreed to a settlement.
In the short-term, for current and 2015-plan year exchange enrollees, Cigna is agreeing to move all generics into generics tiers, end step therapies and adopt a $200 per month limit on costs for the common HIV/AIDS drugs Atripla, Complera, Stribild and Fuzeon.
For 2016 and beyond, the insurer will work with state regulators and groups including the AIDS Institute to develop a comprehensive approach to the complex issue of making HIV/AIDS medications accessible and affordable.
"I appreciate Cigna taking proactive steps to address these allegations," said McCarty. "I am committed to making sure insurers are not acting in a manner that is discriminatory and inconsistent with Florida law and this shows Cigna is committed to those principles as well."
This past spring, the AIDS Institute and the National Health Law Program filed a federal complaint against Cigna, Aetna's Coventry, Humana and Preferred Medical Plan, arguing that their Florida plans were violating the Affordable Care Act's nondiscrimination provisions by placing all HIV/AIDS medications in specialty drug tiers with higher out-of-pocket costs.
The groups' complaint was limited to insurers in Florida and the settlement with Cigna is limited to its Florida exchange plans, but the advocates contend that other insurers around the country are placing similar limits on HIV/AIDS drugs that could run afoul of the ACA. And while Florida regulators are working with Cigna and other insurers to resolve the groups' concerns, the federal Department of Health and Human Services' Office for Civil Rights is still reviewing the original complaints -- and could step in to address the issue nationally.