How a Florida Decision on HIV Medications May Affect California

By David Gorn, California Healthline

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

The change will reduce out-of-pocket 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). Wayne Turner, staff attorney at NHLP, says 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."

Other advocates say the change will certainly help the effort to end adverse price-tiering in California, but aren't so sure of the direct impact. Anne Donnelly is director of public policy for the San Francisco-based Project Inform. Project Inform published an analysis of the medication formularies used by plans in Covered California and has participated in outreach efforts held 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. ... It's that 'tipping point' idea. It will start to tip insurers in that direction."

The next step, NHLP attorney Turner says, 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."