Vol 23, 2014 Annals of Health Law 47
THE ACA AND PEOPLE LIVING WITH HIV/AIDS
Insurance providers may require the insured to pay between twenty-five
percent and one-third of the cost of a medication on tier four or five.154
Medications that insurance providers label as tier four or five are commonly
used by people with chronic health conditions.155 In 2011 for example,
Anthem Blue Cross created a fourth drug tier that charged higher co-pays
than any of the three lower tiers that included complex conditions like
HIV/AIDS and cancer.156 This has resulted in an explosion in the cost of
such life-saving medication for people with chronic conditions, who are
forced to pay.157 And while PPACA imposes some limits on cost sharing,
providers will still be allowed to charge co-pays of up to $6000 for an
individual and $12,000 for a family.158
Recognizing the financial burden imposed upon the insured by these
formularies, state actors have begun acting to protect both the HIV
community and others with chronic conditions.159 For example,
Congressional Representatives Bob McKinley and Lois Capps recently
introduced a bill entitled the Patients Access to Treatment Act 2013.160
This bill limits cost sharing by requiring medications covered under
specialty drug tiers to be covered at the equivalent dollar amount of
medications in non-specialty drug tiers.161
154. See id. (telling the stories of insured whose medical service providers required them
to pay twenty-five percent and one-third of the cost of their medications).
155. See id. (reporting how the advent of specialty drug tiers have made many
medications prohibitively costly for people with complex medical conditions like cancer,
multiple sclerosis, and others).
156. ANTHEM BLUE CROSS, COMING SOON: A NEW TIERED DRUG LIST FOR YOUR GROUPS
(Nov. 2011), available at https://www.anthem.com/ca/health-insurance/nsecurepdf/
157. See Kolata, supra note 152 (explaining that some patients with chronic conditions
could possibly end up paying more than their monthly income).
158. See Randi Hernandez, Specialty Drug Tier Restrictions Proposed in
New Legislation, SPECIALTY PHARMACY TIMES (Feb. 12, 2013), http://www.specialty
(quoting Congressional Representative David McKinley on the Patients Access to Treatment
159. See Memorandum from Sen. Bob Mensch on A Study of Specialty Drug
Prescription Drugs to all Senate members (Mar. 1, 2013), available at http://www.pasen.gov/
(introducing legislation to direct a senate committee to conduct a study of specialty tier
prescription drugs to determine the impact on health care access and patient care); Seth
Hemmelgarn, Ma Takes Aim at HIV Drug, Other Co-Pays, BAY AREA REP. (Feb. 16, 2011),
available at http://ebar.com/blogs/ma-bill-takes-aim-at-hiv-drug-co-pays/ (introducing
legislation aimed at stopping health insurers from dramatically increasing the cost of
medications to California citizens living with HIV).
160. Hernandez, supra note 158.
161. See id.