HIV Medication Decision in Florida May Have Implications in California

Closeup Money rolled up with pills falling out, high cost, expensive healthcare
by David Gorn, California Healthline, Wednesday, April 1, 2015

A health insurer in Florida last week agreed to lower the price of some HIV medications, moving them from a specialty tier to a generic medication tier.

The change will reduce copayments from roughly $1,000 a month for some medications to anywhere from $5 to $100, according to advocates. The change goes into effect in Florida on June 1.

The move by Aetna was prompted, in part, by a lawsuit filed by the National Health Law Program (NHLP, also known as NHeLP). According to Wayne Turner, staff attorney at NHLP, the Florida news has ramifications in California — for HIV/AIDS patients, and possibly for others with conditions requiring specialty medications.

“The formularies in California have been more balanced than other parts of the country, so it’s not the same as Florida,” Turner said. “But there definitely are implications for California. This will have direct impact for HIV/AIDS patients in California.”

It will certainly help the effort to end adverse price tiering in California, though it may not be such a direct effect, said Anne Donnelly, director of public policy for Project Inform, based in San Francisco. Project Inform published an analysis of the medication formularies used by plans in Covered California and has participated in stakeholder-outreach efforts convened by exchange officials to address the issue.

“Whether or not it will have a direct effect is a bit of a question, just because there’s a lot of work already going on here in California, and a lot of progress being made, particularly with Covered California,” Donnelly said. “We’re thrilled [NHLP] won that lawsuit, and it will help. The way I think it will help is it’s that tipping point idea. It will start to tip insurers in that direction.”

The next step, Turner said, is to apply that shift from specialty to generic tier to other conditions with expensive treatment costs.

“Aetna’s announcement protects people living with HIV/AIDS, but not those managing other serious or disabling medical conditions requiring costly medications that are often placed in similarly high cost-sharing tiers,” Turner said. “[We] will continue our efforts so that all low-income individuals can … access the care they need,” Turner said.

Source: California Healthline, Wednesday, April 1, 2015