Kaiser Permanente reverses coverage change for HIV drugs, but cost concerns remain with other insurers

Some HIV-positive Bay Area residents have expressed relief that Kaiser Permanente has reversed a decision that they say could have made HIV/AIDS drugs unaffordable for many Kaiser members.

But other insurers in California have similarly raised costs for those medications, and one Peninsula lawmaker has introduced legislation to combat the price hikes.

Under the changes, which took effect Jan. 1 and were reversed by Kaiser last week, many HIV/AIDS medications were reclassified as specialty drugs, and a 20 percent co-insurance payment was required each time a prescription was filled.

Brandon, an HIV-positive San Francisco resident who declined to give his last name, said he was shocked when he did the math and learned his out-of-pocket costs for medications might increase by $800 per month. In a Facebook post made prior to Kaiser's announcement that it was reversing the change in coverage, the hospitality industry worker wrote, “My pills are approximately $4,000 a month. There is no way I can afford to stay on them now.”

But in a statement released on Friday, San Francisco Supervisor Scott Wiener announced that Kaiser officials had informed him they were not only reversing the change in coverage, but also reimbursing Kaiser members who had paid the larger coinsurance amounts to receive the specialty tier drugs.

Kaiser Vice President John Nelson explained that the drugs in question were being removed from the new specialty-tier classification and put back in the brand tier, where only the fixed co-payments members were previously accustomed to paying would apply.

Wiener, who has called for hearings on the matter because the issue still exists with other insurers, noted that people living with HIV were not the only ones affected by the change in cost sharing. The supervisor said one example was a resident from his district who has celiac disease, an autoimmune disorder occurring with the ingestion of gluten, would now be forced to pay $600 per month for her medications.

A Kaiser spokesman was unable to comment on whether drugs for conditions other than HIV/AIDS would also be removed from the specialty tier pricing.

State Assemblyman Rich Gordon, D-Menlo Park, recently introduced Assembly Bill 339 that would require that co-payments be reasonable enough to not discourage patient compliance with drug regimens. The legislation would also prohibit insurers from placing medically necessary drugs in their most expensive specialty drug tiers.

Wiener said some of his constituents believed the now-reversed change in coverage had been an attempt to circumvent the Affordable Care Act's rule banning discrimination against people with pre-existing conditions.

Addressing that concern, Gordon said, “Are some insurers trying to weed people out? I can't prove that, but if I'm buying insurance and I see that the medications I need are very highly priced, I'm going to go looking for another plan.”

State Deputy Insurance Commissioner Janice Rocco said Anthem Blue Shield and Health Net are among the insurers who recently implemented specialty-drug tiers similar to the one Kaiser had adopted, and most health care providers have placed some HIV medications in their specialty categories.

Last year, the state Department of Insurance urged Covered California to include a monthly cap on co-payments in its 2015 plan design, Rocco said. But according to Rocco, Covered California rejected that idea, citing fears that a monthly cap might cause insurers to raise premiums.

Rocco claimed, however, that a monthly cap wouldn't raise premiums because yearly caps on out-of-pocket expenses would remain unchanged. A monthly cap would simply allow payers to spread the cost of their contribution over the entire year, she said.

Covered California's board of directors will decide during its March 5 meeting whether to include monthly caps in the 2016 plan design, and Rocco says she'll be there advocating for a monthly cap of about $150 per prescription.

Nelson said his organization shares concerns about drug costs and is part of a special working group convened by Covered California to study the issue. He added that Kaiser members — as well as nonmembers — who cannot afford needed medications might qualify for assistance from Kaiser's medical financial assistance program. For more information, visit http://kp.org/mfa

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