Form Hhs-699 - Discrimination Complaint - Department Of Health And Human Services - Office For Civil Rights (Ocr) Page 12
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13B. UPMC Discriminates Against People Living with HIV in its Plan Design
UPMC has discriminated against people living with HIV by creating a benefits plan that
discourages enrollment by offering HIV medications at cost-prohibitive levels. UPMC offers 12
different silver-level QHP plans that all utilize the same formulary on Pennsylvania’s
Marketplace. At the time of the assessment, during open enrollment when individuals are
selecting plans, none of UPMC’s QHPs provided coverage for Tivicay, a component in one of the
regimens recommended by the Guidelines for first-line treatment. UPMC’s QHPs now cover
Tivicay in a formulary updated on August 1, 2016. UPMC engages in adverse tiering in all of its
plans, placing all but one of the medications for treatment-naïve patients on tiers requiring high
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co-insurance. These plans are far more cost-prohibitive than other silver-level QHPs.
Table 1
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Drug
Big 4 Price
UPMC Cost
Monthly Cost
Percentage of
Sharing
to Insured
Income
Truvada and
$893.82 +
50% + 50%
$822.11
18.6%
Isentress
$750.40
Truvada and
$893.82 +
50% + 50%
$856.22
19.3%
Tivicay
$818.61
Stribild
$1,528.59
50%
$764.30
17.3%
Truvada,
$893.82 +
50% + 50% +
Prezista, and
$700.64 +
$842.23
19%
$45
Norvir
$35.90
Triumeq
$2,174.09
50%
$1,087.05
24.6%
Genvoya
$1,528.52
50%
$764.26
17.3%
The cost sharing imposed by UPMC is a burden on the average Pennsylvania consumer. The
median household income for Pennsylvania is $53,115, although the per capita income is much
lower at $28,912. As illustrated by Table 1 above, a median wage earner living with HIV in
Pennsylvania would have to spend between 15% and 24% of his or her monthly income on the
commonly prescribed HIV medications while enrolled in UPMC plans.
UPMC’s practice of adverse tiering makes HIV care unaffordable to the average Pennsylvanian
and discourages people living with HIV from enrolling in its plans, in violation of the ACA.
Along with the unlawful discrimination, these plans place the structure of the ACA at risk. By
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See Supra 16 (discussing Aetna’s copays of $40 or $75 per month).
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Prices paid by insurers (or by their intermediaries – pharmacy benefit managers) to pharmaceutical companies for
medications are not publicly available. Several indexes exist that provide information about drug prices. Two such
indexes that are widely used are the Average Wholesale Price (AWP) and the Big 4 Price. AWP is considered an
inflated cost estimate. The Big 4 Price is the amount paid by four government agencies – the Department of Veterans
Affairs, the Department of Defense, the Public Health Service, and the U.S. Coast Guard – and includes large,
negotiated discounts. For this reason, it is considered a very low estimate of the price paid by private insurance
companies. In this analysis, we use the Big 4 pricing index to conservatively estimate costs for private insurers. The
actual prices paid by insurers and passed on to consumers are likely to be even higher than the estimates presented
here.
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