Patient Access to HIV Drugs in Exchange Plans Is Limited Compared to Other Sources of Coverage

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New analysis from Avalere finds that only 16 percent of silver exchange plans in 2015 cover all top HIV drug regimens with cost sharing less than $100 per month per regimen. While almost half of plans include all 10 of the most commonly used HIV regimens on their formularies, many plans charge higher out-of-pocket costs for these drugs.
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Medication access is a combination of drug coverage (inclusion of all drugs within a regimen on a plan’s formulary) and patient costs (out-of-pocket expenses resulting from copays or coinsurance). Because drug resistance, side effects, or pill burden, HIV patients have unique treatment needs and having comprehensive coverage for these products can be particularly important. Moreover, how much a patient pays out-of-pocket is linked to adherence to medications over time.

“Ensuring individuals living with HIV have affordable access to their medications is critical both for maintaining the health of the patient but also for improving public health by limiting disease transmission,” said Caroline Pearson, senior vice president at Avalere.

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Within a given market, HIV patients can seek to make informed shopping decisions by enrolling in a plan with better coverage for HIV medications. However, availability of plans with broad access to these products varies significantly by state. Indeed, as shown in the map below, consumers in 31 states and the District of Columbia will find a majority of plans cover fewer than 7 of the top regimens and / or require cost sharing over $200 per month. Conversely, a majority of plans in 5 states cover all 10 regimens with cost sharing of $100 or less per month.

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These findings highlight differences in the benefits found in the exchange market when compared to other potential sources of coverage for people with HIV.

Traditionally, many uninsured and underinsured patients accessed HIV therapies through AIDS Drug Assistance Programs (ADAPs), which offer generous coverage with little to no cost sharing for patients.1 Analysis of 2015 ADAP formularies reveals that 47 out of 50 state ADAP programs (plus DC) cover all 10 of the 10 most commonly prescribed HIV treatment regimens included in this analysis. The three states that do not cover all 10 regimens (MT, RI, SD) cover 9 out of 10. Some but not all ADAPs offer wrap-around coverage to reduce enrollee’s drug cost sharing in exchanges.

Meanwhile, in the employer market, HIV drugs are widely covered on generic and preferred brand tiers and are almost never placed on a specialty tier. Prior analysis by Avalere found that single source HIV medications were subject to utilization management (UM) only 8 percent of the time in the employer market, and were placed on the specialty tier just 3 percent of the time by employer sponsored plans.2 In contrast, 30% of silver exchange plans placed all 10 treatment regimens on the highest tier.

As the 2016 exchange open enrollment period begins, it will be important to assess whether these trends in HIV drug coverage persist to ensure patients who need these drugs enroll in plans with broad access.

Avalere conducted additional analysis on HIV drug access in exchanges.

The full report is available here.


Avalere analyzed coverage, cost sharing, and specialty tier placement of the 10 most commonly prescribed HIV treatment regimens by market share in 2014 Q4, as reported by Ipsos U.S. HIV Monitor. The analysis included formularies for all silver plans in 50 states and D.C. in 2015. Coinsurance dollar amounts were estimated using averaged wholesale acquisition cost (WAC) across all regimens.3

This analysis was funded by Gilead Sciences. Avalere maintained editorial control over the content of the analysis and release.

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