Some individuals with HIV/AIDS who purchased 2015 silver-level plans through Covered California and other exchanges under Affordable Care Act faced limited coverage for prescription drug treatments, as well as large out-of-pocket costs, according to a recent analysis by Avalere, Kaiser Health News‘ “Insuring Your Health” reports (Andrews, “Insuring Your Health,” Kaiser Health News, 11/13).
For the analysis, researchers looked at formularies for silver plans sold in all 50 states and Washington, D.C., for the 2015 coverage year (Pearson, Avalere report, November 2015). On average, silver plans cover 70% of enrollees’ medical costs.
Key Findings
The researchers found that many 2015 silver-level exchange plans in 31 states — including California — and Washington, D.C., had “restrictive access” to HIV/AIDS medications, meaning they:
- Covered fewer than seven of the 10 most common drug treatment options for HIV/AIDS; or
- Required consumers to pay more than $200 in monthly cost sharing.
Meanwhile, the analysis found that just 16% of exchange plans in those markets covered all 10 of the drug options and charged under $100 in monthly cost sharing.
Study author Caroline Pearson, a senior vice president at Avalere, said, “Typically plans have a relatively unified formulary state to state, but HIV is the exception.” Pearson added that she does not expect major changes in HIV/AIDS drug benefits for silver-level exchange plans sold for the 2016 coverage year (“Insuring Your Health,” Kaiser Health News, 11/13).
