Kaiser Permanente Reverses Decision to Move HIV Medications to Specialty Tier in California, Reduces Out-of-Pocket Cost for Patients

SAN FRANCISCO, February 23, 2015—Project Inform and San Francisco AIDS Foundation applaud Kaiser Permanente’s decision last week to revise its 2015 drug categorization which put all HIV medications in the highest specialty tier in the California marketplace. Pricing HIV medications in this tier would have required consumers to pay up to 30% of the price of their prescriptions out of pocket, an increase of several hundred dollars per month in some cases. Kaiser will also reimburse those who paid the higher cost sharing prior to this decision.

Pricing HIV medications in this way would have resulted in decreased access to HIV medications, including the medication used for pre-exposure prophylaxis (PrEP), which could interrupt treatment for those living with HIV and those using PrEP to prevent acquisition of the virus. Consistent access to medication is critical to preserving individual health and to maintaining a non-detectable viral load, which prevents transmission of the virus to others. In the case of PrEP, medications should be taken on a daily basis to ensure protection. 

“Historically, Kaiser has been a great partner to the HIV community and has been a leader in California in the prevention and care of HIV,” said Neil Giuliano, San Francisco AIDS Foundation CEO. “This move signifies their ongoing commitment to working collaboratively to better the health of this community.” 

Last week’s decision impacts pricing for HIV medications only for patients covered under Kaiser Permanente health plans in California. Medications for other chronic conditions, like hepatitis C, are still priced in the highest specialty tier.

“We are deeply appreciative of Kaiser making this move in California. It is imperative, too, that this example be used by all of Kaiser plans around the country so that Kaiser patients have equal access to HIV medications regardless of where they live,” said Dana Van Gorder, executive director at Project Inform. “We also urge Kaiser to look at their tiering practices for other drugs, such as curative treatments for hepatitis C, which are currently in the highest specialty tier in all Covered California plans.” 

Kaiser Permanente, Project Inform, and other groups have also been engaged in the Covered California specialty drug workgroup, which aims to assure that Covered California’s contracted health plan formularies meet consumer needs with regards to their approach, transparency, access and cost sharing.

“We are hopeful that the recommendations for effective standards and regulations being developed by this group will be implemented in all marketplace plans in California and that this process will be a model for other states to follow,” said Anne Donnelly, director of health care policy at Project Inform. “We want California to set an example for the other states in how to create a more equitable benefits design.”

These conversations are the critical first steps to ensuring equal access. Other plans in Covered California and in other marketplaces continue to place all or most of the HIV drugs on the highest cost sharing tiers. Additionally many other classes of drugs are also unaffordable for the average consumer. Finally, the missing players in these conversations, however, are the pharmaceutical companies,” said Courtney Mulhern-Pearson, director of state and local affairs at the San Francisco AIDS Foundation. “Efforts to ensure appropriate patient access and reasonable patient cost sharing are not likely to be fully successful without the companies considering their choices on drug pricing and price increases.”


About Project Inform

Project Inform is a nonprofit education and advocacy organization that believes it is possible to create the first generation free of HIV and hepatitis C within the next decade. To achieve that dream, we focus our work in four areas: drug development, bio-medical prevention, education, and health care access.

Project Inform encourages the development of better treatments and cures for both HIV and hepatitis C. We advocate for innovative, medically based prevention strategies. We provide up-to-date, life-saving information to help people living with HIV and hep C make the best choices regarding their treatment and care. And we press governments to set policies and assure unlimited access to affordable health care that will one day end the HIV and hep C epidemics.

For more information, visit www.projectinform.org.

About San Francisco AIDS Foundation

No city experienced epidemic levels of HIV faster than San Francisco. At San Francisco AIDS Foundation, we work to end the epidemic where it first took hold, and eventually everywhere. Established in 1982, our mission is the radical reduction of new infections in San Francisco. Through education, advocacy, and direct services for prevention and care, we are confronting HIV in communities most vulnerable to the disease. We refuse to accept that HIV transmission is inevitable. More information about the foundation is available at sfaf.org.


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