Some Prescription Formularies Discourage HIV Patient Enrollment

Douglas B. Jacobs B.S., MD/MPH Candidate Harvard T.H. Chan School of Public Health Interview with:
Douglas B. Jacobs B.S., MD/MPH Candidate

Harvard T.H. Chan School of Public Health

Medical Research: What is the background for this study?

Response: In May 2014, a formal complaint submitted to the Department of Health and Human Services contended that four Florida insurers were structuring their formularies in a way that discouraged enrollment from HIV positive beneficiaries. These insurers placed all HIV drugs, including generics, on the highest cost-sharing tiers.

This formal complaint served as the impetus for this research. We wanted to discover if this was a phenomenon that was isolated to Florida, or if it was national in scope, and what the implications would be for HIV positive beneficiaries. As such, we analyzed what we called “adverse tiering”—in which all drugs for certain conditions are placed in the highest cost sharing tiers—in 12 states in the federal marketplace. We compared cost-sharing for a commonly prescribed class of HIV medication, called Nucleoside Reverse Transcriptase Inhibitors, or NRTIs.

Medical Research: What are the main findings?

Response: We found that 25% of the plans examined used discriminatory drug tiering for Nucleoside Reverse Transcriptase Inhibitors. The differences in out-of-pocket HIV drug costs between adverse-tiering plans (ATPs) and other plans were stark. People in ATPs on average paid three times more for HIV medications than people in non-ATP plans, with a nearly $2,000 annual difference even for generic drugs. Even though annual premiums in the ATPs tended to be lower than other plans, the high cost of HIV drugs in the ATPs meant that, on average, a person with HIV would pay $3,000 more for treatment each year than if he or she had instead enrolled in a non-ATP plan.

Medical Research: What should clinicians and patients take away from your report?

Response: Patients who feel like they might be paying too much for their drugs might want to examine their plans’ formularies, which should be available either on insurers’ web sites,, or state-based exchanges. Patients may also want to ask peers with similar health conditions how much they pay for medications. Finding out the price of medications is not straightforward, but with some persistence, patients may be able to switch to a better plan to save a significant amount of money.

Clinicians should be aware of the vast cost-sharing discrepancies between different plans. For patients who complain that they are paying too much for drugs, clinicians could recommend searching for alternative plans. Moreover, even within a single plan, there may be alternative drug therapies that are significantly cheaper for patients. Oftentimes, clinicians do not discuss the cost of treatments with their patients. However, armed with the knowledge that another plan might save a patient thousands of dollars annually, perhaps more clinicians will broach the subject.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: Future research should focus on the impact of marketplace plan designs on beneficiaries. The marketplace plan data is publicly accessible online, and so it is surprising that more published research has not examined these plans. Marketplace beneficiaries stand to save thousands of dollars with timely, consumer-driven information, which is especially important given that these beneficiaries tend to be lower income (as many qualify for subsidies).

Overall, the prohibition of discrimination on the basis of health status was one of the Affordable Care Act’s chief accomplishments, and one of its most popular features. Preventing other forms of financial discrimination on the basis of health status will require ongoing oversight.

Citation: upcoming

Using Drugs to Discriminate—Adverse Selection in the Insurance Marketplace
New England Journal of Medicine (01/29/15) Vol. 372, No. 5, P. 399 Jacobs, Douglas B; Sommers, Benjamin D. Harvard School of Public Health Interview with:, Douglas B. Jacobs ScD, & Harvard School of Public Health (2015). Some Prescription Formularies Discourage HIV Patient Enrollment