Cost of HIV Medications in the Illinois Health Insurance Marketplace

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1 Cost of HIV Medications in the Illinois Health Insurance Marketplace March 13, 2014 To help people with HIV choose health insurance marketplace plans, the AIDS Foundation of Chicago (AFC) has collected information on HIV medication coverage for each plan. This document gives examples of what a person with HIV might pay for HIV medications. Keep in mind: Do not rely on the information in this document to choose a plan it s only a guide. Consult a trained enrollment assister for help in selecting a plan. You can reach AFC s navigators at , ext Always verify medication coverage directly with a plan before enrolling. Insurance companies can change their coverage without telling consumers. We only looked at the cost and coverage of a few HIV medications. Contact the plans directly if you take medications that are not listed here. Act fast! The deadline for enrolling in a marketplace plan for 2014 is Monday, March 31. ADAP can help! If you sign up for the Illinois AIDS Drug Assistance Program (ADAP) and enroll in a coordinating plan, you won t pay premiums or any out-of-pocket costs for HIV medications. Read more about ADAP below. Need help choosing a plan? For help applying for coverage, either Marketplace plans or Medicaid, please contact AFC's health insurance navigators at Ext: 350. All of our navigators are familiar with the unique concerns of people impacted by HIV. HIV medications are in many cases unaffordable AFC s analysis shows that two companies BlueCross BlueShield and Land of Lincoln offer HIV medications with affordable out-of-pocket costs. In many of these two company s plans, a complete HIV regimen would cost $25-$150 per month. However, HIV medications are far more expensive and likely unaffordable for nearly all people with HIV in Aetna, Coventry, Health Alliance, and Humana plans. In most cases, HIV medications are on the highest medication tier, requiring a co-insurance payment of as much as 50%. This results in estimated monthly costs of $1,126 for Atripla (Aetna), $1,071 for Truvada + Prezista + Norvir (Coventry), a more reasonable $200 for Stribild (Health Alliance), or $862 for Truvada + Isentress (Humana). Concerted advocacy will be needed to ensure that HIV medications are affordable in all plans. AFC is committed to leading this advocacy at the state and federal levels.

2 The Illinois AIDS Drug Assistance Program (ADAP) can help! Fortunately, if you enroll in the Illinois AIDS Drug Assistance Program (ADAP), they will pay the cost of most HIV medications on plans purchased through the marketplace. ADAP covers these costs because successfully treating HIV has significant benefits for individuals with HIV, as well as the community. People with HIV who have an undetectable viral load have better health outcomes. Moreover, they are far less likely to transmit HIV in the community. People enrolled in ADAP will not pay monthly premiums or any out-of-pocket costs for HIV medications. However, you must select a Silver, Gold or Platinum plan from one of these insurance companies: Aetna Blue Cross Blue Shield Health Alliance Humana If you are eligible for ADAP you must select one of these plans in order to receive any benefits. For more information, contact ADAP at or visit Pre-Exposure Prophylaxis (PrEP) People who are not infected with HIV may be able to take a medication to help prevent infection. Currently only one medication, Truvada, is approved for this use. To date, AFC has not heard reports of insurance companies denying coverage of Truvada as PrEP. The monthly cost of Truvada can be found in the plan information below and is the same cost as Truvada used to treat HIV. For more information on insurance company coverage of Truvada for PrEP, visit Important notes The regimens we chose to examine are the preferred regimens according to the Department of Health and Human Services. (Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at All coverage information was accessed during the last two weeks of February 2014, using the Marketplace website (healthcare.gov), the health insurance companies' websites, and calls to insurance companies' customer service representatives. This information may change at any time and should be verified with the insurance company before enrolling in any plan. When calculating the cost of coinsurance, we based this on the Average Wholesale Price of medications as listed in the 2013 Positively Aware HIV Drug Guide, which can be found here: 2

3 Actual prices will vary between pharmacies and consumers should check with pharmacies before purchasing medications or selecting a plan that relies on co-insurance. Consumers should consider selecting a plan that requires a copay rather than co insurance since a copay is a fixed and predictable amount of money and is typically considerably less than a coinsurance when applied to the costly medications used to treat HIV. More Information This document was prepared by Daliah Mehdi, Chief Clinical Officer, AIDS Foundation of Chicago, Dmehdi@aidschicago.org, Plan Information Aetna Silver, Gold, and Platinum level plans from Aetna are compatible with ADAP. If you are enrolled in ADAP you will not pay anything for these medications. The Aetna marketplace plans use the Four Tier Open Formulary, which can be accessed here Aetna designates its formulary tiers as follows. Tier Description 1 Preferred generics 2 Preferred brands 3 Non-preferred drugs 4 Preferred specialty drugs Coverage of preferred regimen drugs (tiers 2 and 3) under each plan is outlined below. Note: Coverage under all plans only begins after deductible has been met. Until deductible is met, client pays full cost of medications. Plan Name Tier 2 Tier 3 Bronze Advantage 5750 PD $75 copay 50% coinsurance Advantage % covered 100% covered Advantage Plus 5500 PD 50% coinsurance 50% coinsurance Silver Classic 3500 PD $60 copay 50% coinsurance Classic 5000 $60 copay 50% coinsurance Gold Premier 2000 PD $50 copay 50% coinsurance 3

4 The costs for components of preferred regimens when a 50% coinsurance is used are outlined in the following table. Medication Tier AWP* 50% coinsurance Atripla 3 $2, $1, Truvada 3 $1, $ Reyataz 3 $1, $ Prezista 3 $1, $ Isentress 3 $1, $ Norvir 3 $ $ Stribild Not covered $2, N/A Tivicay 2 $1, $ Epzicom 3 $1, $ * AWP is Average Wholesale Price as listed in the Positively Aware HIV Drug Guide. Using the above costs, the calculated monthly cost for each preferred regimen is summarized below. Advantage 5750 PD Advantage Plus 5500 PD Classic 3500 PD Classic 5000 Premier 2000 PD Atripla $1, $1, $1, $1, $1, Truvada + Reyataz + Norvir $1, $1, $1, $1, $1, Truvada + Prezista + Norvir $1, $1, $1, $1, $1, Truvada + Isentress $1, $1, $1, $1, $1, Stribild not covered, client pays full cost of $2, Tivicay + Epzicom $ $1, $ $ $ Tivicay + Truvada $ $1, $ $ $ Blue Cross Blue Shield of Illinois (BCBS) Silver, Gold, and Platinum level plans from BCBS are compatible with ADAP. If you are enrolled in ADAP you will not pay anything for these medications. All silver and gold level plans offered through the Marketplace use either the 2014 Standard Formulary or the 2014 Generics Plus Formulary. Both formularies offer the same Antiretrovirals at the same tier levels. Links to both formularies can be found here 4

5 BCBS designates its formulary tiers as follows. Tier Description 1 Preferred generic 2 Non-preferred generic 3 Preferred brand 4 Non-preferred brand 5 Specialty The costs for components of preferred regimens are outlined in the following table. Medication Tier Cost/month - all silver plans and Blue Precision Gold HMO Cost/Month - all gold plans, except Blue Precision Gold HMO Atripla 3 $50 $35 Truvada 3 $50 $35 Reyataz 3 $50 $35 Prezista 3 $50 $35 Isentress 3 $50 $35 Norvir 3 $50 $35 Stribild 3 $50 $35 Tivicay 3 $50 $35 Epzicom 3 $50 $35 Using the above costs, the calculated monthly cost for each preferred regimen is summarized below. Silver plans and Gold Precision HMO Gold plans, except Gold Precision HMO Atripla $50 $35 Truvada + Reyataz + Norvir $150 $105 Truvada + Prezista + Norvir $150 $105 Truvada + Isentress $100 $70 Stribild $50 $35 Tivicay + Epzicom $100 $70 Tivicay + Truvada $100 $70 5

6 Coventry Coventry plans are NOT compatible with ADAP. The Coventry drug formulary can be found here c pdf Coventry designates its formulary tiers as follows. Tier Description 1 Preferred generic and select over-the-counter drugs 2 Preferred brand drugs 3 Non-preferred generic and brand drugs 4 Specialty preferred 5 Specialty non-preferred Coverage of preferred regimen drugs (tiers 4 and 5) under each plan is outlined below. Plan name Tier 4 Coverage Tier 5 Coverage Bronze deductible only PPO 100% after 100% after Bronze $10 copay PPO select Silver $10 copay PPO select Gold $5 copay PPO select 30% coinsurance after 30% coinsurance after 20% coinsurance after 40% coinsurance after 40% coinsurance after 30% coinsurance after The costs for components of preferred regimens are outlined in the following table. Medication Tier AWP* 20% Coinsurance 30% coinsurance 40% coinsurance Atripla 5 $2, N/A $ $ Truvada 5 $1, N/A $ $ Reyataz 4 $1, $ $ N/A Prezista 4 $1, $ $ N/A Isentress 4 $1, $ $ N/A Norvir 4 $ $61.72 $92.58 N/A Stribild 5 $2, N/A $ $ Tivicay 5 $1, N/A $ $ Epzicom 5 $1, N/A $ $ * AWP is Average Wholesale Price as listed in the Positively Aware HIV Drug Guide. 6

7 Using the above costs, the calculated monthly cost for each preferred regimen is summarized below. Bronze and Silver $10 copay PPO select Gold $5 copay PPO select Atripla $ $ Truvada + Reyataz + Norvir $1, $ Truvada + Prezista + Norvir $1, $ Truvada + Isentress $ $ Stribild $ $ Tivicay + Epzicom $ $ Tivicay + Truvada $1, $ Health Alliance Silver, Gold, and Platinum level plans from Health Alliance are compatible with ADAP. If you are enrolled in ADAP you will not pay anything for these medications. The Health Alliance formulary can be found here: Health Alliance designates its formulary tiers as follows. Tier Description 1 Generic 2 Preferred brand drugs 3 Non-preferred brand drugs 4 Preferred specialty drugs 5 Non-preferred specialty drugs 6 Non-formulary specialty drugs 7

8 Coverage of preferred regimen drugs (tiers 3 and 5) under each plan is outlined below. Tier Guide HMO 3150/ % 6350/12700 Rx3 (Bronze) 30/ / % 5500/11000 Rx5 (Silver) * Guide HMO 1750/ % 5500/11000 Rx2 1750/ % 5500/1000 Rx3 (Silver) 1750/ % 5000/10000 Rx2 Atripla 5 $ $ $ $ $ $ Truvada 5 $ $ $ $ $ $ Reyataz 3 $80.00 $80.00 $70.00 $80.00 $70.00 $70.00 Prezista 3 $80.00 $80.00 $70.00 $80.00 $70.00 $70.00 Isentress 3 $80.00 $80.00 $70.00 $80.00 $70.00 $70.00 Norvir 3 $80.00 $80.00 $70.00 $80.00 $70.00 $70.00 Stribild 5 $ $ $ $ $ $ Tivicay 5 $ $ $ $ $ $ Epzicom 3 $80.00 $80.00 $70.00 $80.00 $70.00 $70.00 Benefits begin * Note: Benefits begin Benefits begin after deductible pharmacyspecific after deductible after deductible met met met deductible of $250 must be 20/ / % 4000/8000 Rx2 (Gold) 2100/4200 0% 2100/4200 RxDED Using the above costs, the calculated monthly cost for each preferred regimen is summarized below. 2000/4000 0% 2000/4000 RxDED Guide HMO 3150/ % 6350/12700 Rx3 (Bronze) 30/ / % 5500/11000 Rx5 (Silver) * Guide HMO 1750/ % 5500/11000 Rx2 (Silver) 1750/ % 5500/1000 Rx3 (Silver) 1750/ % 5000/10000 Rx2 (Silver) Atripla $200 $200 $140 $200 $140 $140 Truvada + Reyataz + Norvir $360 $360 $280 $360 $280 $280 Truvada + Prezista + Norvir $360 $360 $280 $360 $280 $280 Truvada + Isentress $280 $280 $210 $280 $210 $210 Stribild $200 $200 $140 $200 $140 $140 Tivicay + Epzicom $280 $280 $210 $280 $210 $210 Tivicay + Truvada $400 $400 $280 $400 $280 $280 Benefits begin * Note: Benefits begin Benefits begin after deductible pharmacyspecific after deductible after deductible met met met deductible of $250 must be met before benefits begin 20/ / % 4000/8000 Rx2 (Gold) 2100/4200 0% 2100/4200 RxDED (Gold) 2000/4000 0% 2000/4000 RxDED (Gold) 8

9 Humana Silver, Gold, and Platinum level plans from Humana are compatible with ADAP. If you are enrolled in ADAP you will not pay anything for these medications. All marketplace plans use either the Rx5 Plus formulary or the HDHP Plus formulary. Links to both formularies can be found here Humana designates its formulary tiers as follows. Tier Description 1 Preferred generic 2 Non-preferred generic 3 Preferred brand 4 Non-preferred brand 5 Specialty Note that all of the high deductible health plans (HDHPs) use the HDHP Plus formulary. Under these plans there is no cost to the client for medications once the deductible has been met. Until the deductible is met the patient is responsible for 100% of the cost of the medication. The coinsurance amount for each Humana plan offered is in the following table. Plan type Plan name Formulary Name Coverage HMO Connect Basic 6350/6350 HDHP Plus 100% after deductible Connect Bronze 6300/6300 HDHP Plus 100% after deductible Connect Bronze 4850/6350 Rx5 Plus 50% coinsurance after Connect Silver 4600/6300 Rx5 Plus 50% coinsurance after Connect Gold 2500/3500 Rx5 Plus 32% coinsurance after PPO Connect Platinum 1000/5000 Rx5 Plus 32% coinsurance after National Preferred Basic 6350/6350 HDHP Plus 100% after deductible National Preferred Bronze 6300/6300 HDHP Plus 100% after deductible National Preferred Bronze 4850/6350 Rx5 Plus 50% coinsurance after National Preferred Silver 4250/6250 Rx5 Plus 50% coinsurance after National Preferred Silver 3650/3650 HDHP Plus 100% after deductible National Prefered Gold 2500/3500 Rx5 Plus 32% coinsurance after National Prefered Platinum 1000/1500 Rx5 Plus 32% coinsurance after 9

10 The costs for components of preferred regimens are outlined in the following table. Medication Tier AWP* 32% Coinsurance 50% Coinsurance Atripla 5 $2, $ $1, Truvada 5 $1, $ $ Reyataz 5 $1, $ $ Prezista 5 $1, $ $ Isentress 5 $1, $ $ Norvir 5 $ $98.75 $ Stribild 5 $2, $ $1, Tivicay 5 $1, $ $ Epzicom 5 $1, $ $ * AWP is Average Wholesale Price as listed in the Positively Aware HIV Drug Guide. Using the above costs, the calculated monthly cost for each preferred regimen is summarized below. 32% coinsurance 50% coinsurance Atripla $ $1, Truvada + Reyataz + Norvir $ $1, Truvada + Prezista + Norvir $ $1, Truvada + Isentress $ $1, Stribild $ $1, Tivicay + Epzicom $ $1, Tivicay + Truvada $ $1, Land of Lincoln Land of Lincoln plans are NOT compatible with ADAP. The Land of Lincoln formulary can be found here 09% pdf Land of Lincoln designates its formulary tiers as follows. Tier Description 1 Generic 2 Preferred brand drugs Non-preferred brand 3 drugs 4 Specialty drugs 10

11 Coverage of Tier 2 medications is listed below. Plan National Freedom Bronze National Choice Bronze National Premier Bronze National Preferred Bronze National Complete Bronze National Freedom Silver National Choice Silver National Confidence Silver National Freedom Gold National Choice Gold National Preferred Silver National Complete Silver National Elite Silver National Preferred Gold National Premier Silver National Confidence Gold National Complete Gold National Elite Gold National Premier Gold Coverage 40% co-insurance after 40% co-insurance after $50 co-pay after 40% co-insurance after 40% co-insurance after $35 co-pay after $35 co-pay after $40 co-pay $35 co-pay $35 co-pay 30% co-insurance after $40 co-pay $35 co-pay 20% co-insurance after $35 co-pay $25 co-pay $25 co-pay $35 co-pay $35 co-pay The costs for components of preferred regimens are outlined in the following table for plans with coinsurance. Medication Tier AWP* 20% coinsurance 30% coinsurance 40% coinsurance Atripla 2 $2, $ $ $ Truvada 2 $1, $ $ $ Reyataz 2 $1, $ $ $ Prezista 2 $1, $ $ $ Isentress 2 $1, $ $ $ Norvir 2 $ $61.72 $92.58 $ Stribild 2 $2, $ $ $ Tivicay Not covered $1, $ $ $ Epzicom 2 $1, $ $ $

12 Using the above costs, the calculated monthly cost for each preferred regimen is summarized below. 20% coinsurance 30% coinsurance 40% coinsurance $25 copay $35 copay $40 copay $50 copay Atripla $ $ $ $25.00 $35.00 $40.00 $50.00 Truvada + Reyataz + Norvir $ $ $1, $75.00 $ $ $ Truvada + Prezista + Norvir $ $ $1, $75.00 $ $ $ Truvada + Isentress $ $ $1, $50.00 $70.00 $80.00 $ Stribild $ $ $1, $25.00 $35.00 $40.00 $50.00 Tivicay + Epzicom $1, $1, $1, $1, $1, $1, $1, Tivicay + Truvada $1, $1, $1, $1, $1, $1, $1, Note: Since Tivicay is not on formulary (i.e. it is not covered), client pays full price out of pocket for this drug only. All drug costs, including Tivicay, are counted towards deductible and out of pocket maximum. 12