Groups Propose Strategies for Health Insurers to Optimize Coverage for People with HIV

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A joint statement from the HIV Medicine Association and the American Academy of HIV Medicine has been issued:

"In 2014, an estimated 23,000 people with HIV infection will obtain private health insurance coverage through the Affordable Care Act’s marketplaces and more than 26,000 will gain access to Medicaid coverage (a number that would nearly double to 50,000 if all states expanded Medicaid). This represents an unprecedented opportunity to improve health outcomes for people with HIV and promote cost-effective care.

"The HIV Medicine Association (HIVMA) and the American Academy of HIV Medicine (AAHIVM) strongly urge private health insurance plans and Medicaid managed care plans to support high quality, cost-effective care by adopting the policy recommendations outlined below.

1. Follow the HIV Treatment Guidelines:  We strongly urge coverage of all antiretrovirals according to the nationally recognized standard for HIV treatment – The Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents and in Pediatric HIV Infection  (HHS treatment guidelines). As recognized by Medicare and other third-party payers, antiretroviral medications are not interchangeable and substitutions cannot be made even within drug class. Providers and their patients must have access to the full range of biomedical tools available to suppress this infectious and deadly virus.  This includes the appropriate formulation to accommodate pregnant women and elderly and adolescent patients who are unable to tolerate large pills.

2. Apply Reasonable Cost Sharing: High cost sharing presents a major barrier to patients maintaining access to the daily medication regimen required to keep the virus at bay. Plans that place all or most antiretrovirals on the highest sharing tier discriminate against people with HIV and undercut the benefits of health insurance. We strongly encourage plans to apply a copayment or nominal flat fee to antiretrovirals rather than charging co-insurance that requires patients to pay a percentage of the drug’s cost. While antiretrovirals can be expensive, the adverse consequences of treatment disruptions, including drug resistance and virologic failure, lead to more costly interventions, such as hospitalization and treatment of opportunistic infections, and have long-term negative health consequences.  

3. Cover Single Tablet Regimens:  One of the major advances in HIV medicine is the availability of multiple antiretroviral medications as a single tablet regimen (STR). STRs are some of the mostly widely prescribed HIV medications and typically are no more expensive than the sum of their component parts. We urge coverage of STRs to facilitate adherence and improve outcomes.

4. Avoid Cumbersome Prior Authorization Processes:  We strongly discourage imposition of prior authorization requirements for traditionally protected classes of drugs, including antiretrovirals. Such bureaucratic hurdles add administrative barriers and increased costs to the already complex delivery of HIV care. If prior authorization is employed for antiretrovirals, we strongly urge reference to the HHS treatment guidelines and authorization of coverage for 12-month periods.  

5. Institute Effective Pharmacy Practices:  Uninterrupted access to HIV medications is critical to treatment success. For restricted pharmacy networks – particularly those limited to mail order options, policies must be in place to meet the highest standard for timely dispensing of medications and to educate patients on in-network pharmacy policies. We strongly urge health plans to include AIDS Drug Assistance Program (ADAP) pharmacies in their networks and to cover medication therapy management counseling for patients who require support with managing their complex daily drug regimen. We also strongly recommend that health plans allow ADAPs to provide the third-party premium and cost-sharing assistance that is critical to ensuring health care remains affordable for many people with HIV.

6. Include Ryan White Providers in Networks:  Ryan White providers are designated as Essential Community Providers because of their role in serving the most vulnerable patients with HIV. Many people with HIV enrolling in marketplace plans are currently cared for by Ryan White providers. We strongly recommend that health plans include all Ryan White medical providers in their networks to support continuity of care for these patients and to allow them to continue to benefit from the other key services that they offer. 

7. Allow HIV Providers as Primary Care Providers:  Regardless of their specialty training, HIV medical providers often serve as their patients’ primary care provider. We urge health plans to have policies that streamline access to HIV medical providers, including allowing patients to designate them as their Primary Care Provider and instituting standing referrals to HIV providers. Failure to provide direct access to HIV providers leaves patients at risk medically and adds costs and inefficiencies to the delivery system.

8. Implement HIV Quality Measures:  Following nationally recognized HIV care and treatment standards improves health outcomes and lowers healthcare costs. We strongly urge that HIV care be monitored by HIV quality measures. Measures approved by the National Qualify Forum are included in Medicare’s Physician Quality Reporting System and Electronic Health Record Meaningful Use programs as well as the Core Set of Health Quality Measures for Medicaid-Eligible Adults."

Source: HIV Medicine Association and the American Academy of HIV Medicine

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