By Christine Kukka
Blog reviewed and deemed accurate Jan. 2023.
For years, people with pre-existing conditions like chronic hepatitis B struggled to get health insurance. News stories and Michael Moore’s documentary Sicko highlighted insurance companies’ refusal to cover pre-existing conditions and their practice of inflating premium prices if consumers had chronic health problems.
Outraged by industry efforts to cover only low-cost, “healthy” consumers, lawmakers banned discrimination against pre-existing conditions in the Affordable Care Act (ACA – Obamacare). The ACA’s Healthcare Marketplace website promises, “Your insurance company can’t turn you down or charge you more because of your pre-existing health or medical condition like asthma, back pain, diabetes, or cancer.”
While health plans sold on the marketplace can’t openly refuse to insure people with pre-existing conditions, some have devised an insidious way to discourage people with hepatitis B from buying their policies. They have dramatically increased the copays consumers pay out-of-pocket for the two leading hepatitis B antiviral drugs (Viread and generic entecavir) to deliberately make their health plans unaffordable for people with chronic hepatitis B.
When health insurers design plans, they assign each prescription drug a price “tier.” A low-cost generic antibiotic may be a Tier 1 while a new, brand-name drug is assigned a pricier Tier 4 or 5 ranking. A review of several Silver Plans sold on the marketplace shows entecavir and Viread (tenofovir) prices can reach up to $500 a month after the plan’s deductible is met. This deliberate over-pricing of certain drugs to deter people with chronic conditions from buying a health plan is called “adverse tiering” and it violates the ban against discriminating against pre-existing conditions.
For example, a survey of Silver Plans sold on the marketplace in one region found one company placed generic entecavir on a “specialty” Tier 4, which required consumers to pay a minimum of $200 to $300 a month for this vital medication. In contrast, a different company placed entecavir on a Tier 2 rank and charged a more modest $50 monthly copay.
According to legal and medical reports, these insurers’ drug tier designs and their discriminatory cost-sharing requirements deliberately discourage people who desperately medications from enrolling in their plans.
To fight these practices, The AIDS Institute and the National Health Law Program filed complaints in Florida against insurance companies that inflated their HIV drug prices through “adverse tiering” to discourage people living with HIV from buying their plans. At the time of the complaint, one insurance company, Humana, required patients to pay 50 percent of the drug’s retail price for HIV drugs after patients met a $1,500 deductible. The insurers were fined and the drug tiers for HIV drugs were revised to be more affordable, but this “adverse tiering” persists nationwide for hepatitis B and C drugs.
The Hepatitis B Foundation is working to change this discriminatory practice, but it needs your help to file complaints so your state and the federal government can investigate “adverse tiering” in plans sold in your region through the marketplace.
To file a complaint, an individual or organization needs to research Viread (tenofovir) or entecavir prices listed in all Silver Plans advertised in their region’s marketplace website to see if the drug costs are over-priced. People who file complaints don’t have to have hepatitis B, or even buy health plans on the marketplace.
The foundation, in collaboration with the National Health Law Program, has created instructions and a template for consumers and organizations to use to file complaints. Consumers will have to do some research on the marketplace’s website to discover the drug prices in their region, but they can help end discrimination and bring down the rapidly-escalating drug prices found in many health plans.
To review how to research and file a complaint click here. The instruction page provides a link to a template that you can fill in with your local information. For additional information, please contact the foundation at chris.kukka@hepb.org.
Even if you don’t file a complaint, if you shop for healthcare insurance on the marketplace, take time to thoroughly research how much the plan will charge for antivirals to protect your rights and your wallet.
Note: Federal laws that prohibit discrimination against pre-existing conditions apply only to Affordable Care Act health plans sold on the marketplace. If you purchase insurance through your employer, unfortunately there are not as many legal protections in place to prohibit adverse drug tiering. However, research your plan carefully, there may be cafeteria options that allow you to select the most advantageous plan for your treatment needs.