By Dow Jones Business News,
May 29, 2014, 11:50:00 AM EDT
By Louise Radnofsky
Patient advocacy groups are using antidiscrimination provisions in the health-care law as the basis of a complaint
against insurers they say are trying to avoid covering consumers with HIV and AIDS, in one of the first cases of its
The National Health Law Program and the AIDS Institute submitted a complaint to the Department of Health and Human
Services' Office of Civil Rights Thursday morning accusing four health insurers selling individual plans in Florida of
discriminating against consumers with HIV in the way they designed their insurance benefits. The complaint names
Coventry Health Care Inc., a unit of Aetna Inc., Cigna Corp., Humana Inc. and Preferred Medical, a plan based in Coral
The complaint says the four insurers put every HIV drug, even older generics, in the highest tier in their drug
formularies, requiring patients to pay as much as 50% of the cost themselves.
HIV advocacy organizations have said the issue isn't specific to Florida and they believe a decision would
influence plans across the country.
The health law bars insurers from charging customers more based on their medical history when it comes to setting
premiums. The Wall Street Journal reported in December that HIV organizations believed some health insurers had found
other ways to discourage people infected with HIV from signing up for their plans, such as requiring higher copayments
for HIV drugs than they would for other prescriptions.
The two patient advocacy organizations are trying to challenge that practice by using another provision in the
health law that bars any health program that receives federal funds from discriminating on the basis of "race, color,
national origin, sex, age, or disability."
Wayne Turner, a staff attorney for the National Health Law Program, said the complaint appeared to be the first one
that drew on the antidiscrimination provision to go after an insurance plan's benefit design.
A handful of different complaints filed with the Office of Civil Rights have cited the antidiscrimination provision
to challenge other decisions by health insurers.
Alex Kepnes, a spokesman for Humana, and Karen Eldred, a spokeswoman for Cigna, both noted that their company's
plans did cover HIV drugs.
Mr. Kepnes said Humana covered all HIV drugs except brand names when generics were available, and that the insurer
considered most of them to be specialty drugs covered in the same category as treatments for conditions such as
rheumatoid arthritis, multiple sclerosis and growth hormone disorders.
He pointed out that consumers wouldn't have to pay anything when filling their prescriptions after they had hit
their maximum on out-of-pocket costs. Under the health law, no plans can have an out-of-pocket maximum higher than $
6,350 for 2014.
Ms. Eldred said that Cigna covered all HIV drugs that were recognized as medically necessary and also offered
consumers with HIV support managing their condition from a team of nurses, pharmacists and therapy support coordinators.
Officials for Coventry and Preferred Medical didn't immediately respond to requests for comment.
Melinda Beck contributed to this article.
Write to Louise Radnofsky at firstname.lastname@example.org
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