Facing Complaints, BCBS of North Carolina Shifts HIV Drugs to Lower Tiers

Two patient advocacy groups are declaring victory after Blue Cross Blue Shield of North Carolina made midyear formulary changes that shifted several HIV treatments from higher to lower tiers, meaning patients can access them at much lower cost-sharing levels.

In an Aug. 31 press release, the HIV+Hepatitis Policy Institute and the North Carolina AIDS Action Network pointed out that the move came after they filed discrimination complaints with the North Carolina Dept. of Insurance and HHS’s Office for Civil Rights arguing that the Blue Cross NC formulary violated the Affordable Care Act’s prohibitions against discriminatory plan design. The formulary in question is the Blue Cross and Blue Shield of North Carolina Essential Formulary, which applies to ACA marketplace plans sold in the state.

The insurer, however, said it made the changes during a routine formulary update.

“As part of an ongoing quarterly review process, a clinical team updated our formulary tiers in April,” a spokesperson tells AIS Health, a division of MMIT. “This change streamlined drug tiering across multiple drug and condition categories, and, as a result of the changes, some members may have lower out-of-pocket costs when purchasing a prescription.”

The spokesperson adds that Blue Cross NC “stands against discrimination of any kind, including discrimination based on health status, sexual orientation or gender identity. The methodology used to determine tiers for our members’ medications remains consistent across health conditions, using clinical and cost information.”

Before the insurer made changes, its formulary placed almost all HIV drugs on the highest-cost tiers (5 and 6), including some generics, according to the two patient advocacy groups.

Higher Tiers Meant Higher Patient Costs

In their letter to North Carolina insurance officials, the groups point out that those high tier placements can mean hefty out-of-pocket costs for HIV drugs. For example, in the Blue Home Bronze 7000 plan on the ACA marketplace, “cost-sharing for both Tiers 5 and 6 translates into 50 percent coinsurance after a $7,000 deductible for an individual and $14,000 for a family. For Blue Home Silver Preferred 3100, the cost-sharing for Tiers 5 and 6 is 50 percent cost-sharing after a $3,100 deductible for an individual and $6,200 for a family. For Blue Home Gold Standard 2000, cost-sharing for Tiers 5 and 6 is $250.”

After the midyear revision, however, not a single HIV drug was placed on the highest tiers, and the insurer moved 19 generic HIV treatments from Tiers 4, 5, and 6 to Tier 2. Blue Cross NC also removed quantity limits that were previously placed on all HIV medications, the HIV+Hepatitis Policy Institute and North Carolina AIDS Action Network noted. In their press release, the groups said that they haven’t received any formal communication from the state and federal regulators with whom they filed complaints indicating “that they have acted or closed the complaints, and it is not known if NC Blue Cross Blue Shield was fined or forced to make these changes.”

Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, tells AIS Health that he isn’t sure whether the formulary placement his group complained about is common among other formularies or whether Blue Cross NC is an outlier.

Schmid says he “heard about this plan from a pharmacist,” adding that “we may have to conduct a review of all plans to figure this out.” State regulators and CMS’s Center for Consumer Information and Insurance Oversight should be conducting such an examination as well, he contends.

Back in 2016, the Harvard Law School’s Center for Health Law and Policy Innovation filed complaints with HHS’s Office for Civil Rights. The complaints alleged that plans offered by seven insurers — including big names like Humana, Highmark, Independence Blue Cross and UPMC Health Plan — in eight states are discriminatory because they don’t cover drugs that are essential to the treatment of HIV or require high out-of-pocket spending by patients for covered drugs, NPR reported.

“While pleased to see this dramatic turnaround by the insurer, blatant discriminatory plan design and violation of the ACA’s patient protections should not happen in the first place,” Schmid said in the advocacy groups’ news release about the North Carolina insurer’s formulary changes. “As insurers across the country are now submitting their plans for 2024, consumers must be assured that drug formularies are being carefully reviewed to protect all beneficiaries, not just those living with HIV.”

Lately, the HIV+Hepatitis Policy Institute’s main fight has been advocating against attempts to repeal the ACA’s preventive service coverage mandate, which is the subject of federal litigation that appears likely to make it to the Supreme Court. Judge Reed O’Connor of the United States District Court for the Northern District of Texas ruled in March that it’s unconstitutional for the ACA to require that employer and individual market plans must fully cover all services recommended by the U.S. Preventive Services Task Force. He also agreed with plaintiffs that the ACA’s coverage requirement for preexposure prophylaxis (PrEP) for HIV violates the rights of employers with religious objections — a ruling that Schmid and the HIV+Hepatitis Policy Institute fiercely denounced.

Contact Schmid at cschmid@hivhep.org.

This article was reprinted from AIS Health’s weekly publication Health Plan Weekly.

© 2024 MMIT
Leslie Small

Leslie Small

Leslie has been working in journalism since 2009 and reporting on the health care industry since 2014. She has covered the many ups and downs of the Affordable Care Act exchanges, the failed health insurer mega-mergers, and hundreds of other storylines spanning subjects such as Medicaid managed care, Medicare Advantage, employer-sponsored insurance, and prescription drug coverage. As the managing editor of Health Plan Weekly and Radar on Drug Benefits, she writes and edits for both publications while overseeing a small team of reporters who also focus on the managed care sector. Before joining AIS Health, she was a senior editor for the e-newsletter Fierce Health Payer, and she started her career as a copy editor at multiple local newspapers. She graduated with a dual degree in journalism and political science from Penn State University.

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