Access to Medications in South Carolina
Reducing Barriers to Care and Treatment for People Living with HIV
South Carolinians living with HIV currently face barriers to accessing needed medications from their health plans and pharmacy benefit managers. South Carolina health plans and pharmacy benefit managers are engaging in practices that are contrary to the letter and intent of state and federal law.Restricting access to HIV medications can be life threatening for people living with HIV, and dangerous for the public’s health.
Health Plans Restrict Access to Medications
South Carolina health plans typically implement medical management techniques to manage access to HIV medications. Specifically, HIV medications often require prior authorization and/or can only be accessed at specialty pharmacies.
Even a brief interruption in therapy can increasethe risk of clinical progression for people living with HIV. The Department of Health and Human Services has published Guidelines for the Use of Antiretroviral Agents in HIV-1 Infects Adults and Adolescents (the Guidelines).[1]Prior authorization, the guidelines note, results in lost provider time, increased non-adherence among patients, and reduced timely access to medications. The Guidelines also note that step therapy is inappropriate for the treatment of HIV, and that the choice of medication should be made by the individual and his or her treating physician.[2]
Access to HIV medications also benefit people who are not infected with the virus. Viral suppression, meaning that the virus is undetectable, is the ultimate goal for people living with HIV. People who are virally suppressed are 96% less likely to transmit the virus to sexual partners.[3]
The legislatureshould prohibit health plans from requiring enrollees to seek prior approval for all HIV medications before the individual is able to access treatment. It is vitally important that physicians and patients are able to make appropriate medical choices to manage HIV infections.
Pharmacy Benefit Managers Limit Choice of Pharmacies by Enrollees
Health plans and employers contract with pharmacy benefit managers (PBMs) to manage drug coverage that pharmacies dispense.[4] Reportedly, PBMs in South Carolina have notified plan enrollees they cannot access medications from in network pharmacies or alternatively, charge enrollees higher costs for accessing medications outside of pharmacies deemed “preferred.” Oftentimes, PBMs will categorize all HIV medication as “specialty drugs” and require enrollees to obtain these medications only from a limited specialty pharmacy network, excluding the rest of their in network providers.
These practices run afoul of South Carolina law. South Carolina law prohibits an individual or group accident health, or health insurance policy from prohibiting or limiting enrollees access to a pharmacy, as long as the pharmacy agrees to abide by the insurers terms.[5]Insurers must also allow any pharmacy willing to meet its terms and requirements to participate as a contract or in network pharmacy. The legislative intent behind this law is to protect individuals’ freedom to select the pharmacy they prefer. By limiting enrollees’ choices to a very small network of pharmacies—often owned by the PBM—insurers and PBMs are violating South Carolina law. The federal government has also noted that medical management techniques, such as restrictions on pharmacy use and limited pharmacy networks can be discriminatory against people with chronic illnesses such as HIV.[6]
This practice is an obvious transparency issue. Consumers may select a plan based on theapparent ability to access medications from their preferred pharmacy, but then discover they cannot access medications as preferred. Often consumers are notified of the newly restricted pharmacy network only after open enrollment has closed, leaving the consumer stuck in a plan where it is a burden to access needed medications.
This restricted access has a significant impact on organizations who receive payments through the 340B drug pricing program and the patients who rely on these organizations. The 340B drug pricing program is a federally administered program that supports nonprofit organizations who serve the most vulnerable populations, such as federal qualified health centers and Ryan White HIV/AIDS program grantees.[7]340B programs are often run by Federally Qualified Health Centers and AIDS Service Organizations. As such, 340B pharmacies can often provide superior coordination of care for individuals living with HIV, resulting in superior outcomes. In restricting access to a single or few pharmacies, sometimes even to specialty pharmacies owned by the PBMs, insurers and PBMs often exclude 340B participating organizations.
Excluding 340B organizations limits prescription access for the patients they serve. In a recent survey, around 70% of the 340B participating organizations surveyed stated their costs would increase at least 40% without the 340B program. And, during a time period when formularies are restricting access for people living with HIV, more than half of entities surveyed stated the 340B programs allows them to avoid restrictive formularies and results in more medication and device options available.[8]
The South Carolina Legislature could pass meaningful legislation prohibiting pharmacy benefit managers from restricting pharmacy networks. The Pharmacy Patient Protection Acthas been introduced five times since 2007, and most recently the 2015-2016 General Assembly introduced the bill in the 121 Session.[9] If this bill or similar legislation was passed into law, pharmacy benefit managers would be prohibited from imposing different copayments or limiting the days of supply to discriminate against pharmacies, and could not influence the patient’s choice of pharmacy or pharmacist.
Conclusion
South Carolina has the opportunity to improve the access to treatment, the health of South Carolina citizens, and ultimately end the epidemic. Access to HIV medications is necessary not only for the health and life of people with the virus, but to prevent the spread of the virus. When insurers place onerous utilization management criteria on all HIV medications, or PBMs severely limit enrollees’ choice of pharmacy contrary to South Carolina law, they create impermissible roadblocks to access to care for South Carolinians living with HIV.
[1] U.S. Dep’t of Health & Hum. Servs., Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents A1-2 (last updated Jan. 28, 2016).
[2]U.S. Department of Health & Human Servs., Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents F-5-6, (last updated Jan. 28, 2016).
[3] Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365:493–505.
[4] P. Danzon & C. Moh, University of Penn., 2014 ERISA Advisory Council: PBM Compensation and Fee Disclosure 1 (2014).
[5] SC ST § 38-71-147.
[6]80 Fed.Reg. 10,749, 10,820-3; 79 Fed.Reg. 70,674, 70,723.
[7] U.S. Dep’t of Health and Hum. Servs., Health Resources and Services Administration, 340B Drug Pricing Program,
[8] Nat’l Association of Community Health Centers, Benefits of the 340B Drug Pricing Program for Health Centers (2011),
[9] S.C. H 3159, Pharmacy Patient Protection Act (Introduced Jan. 13, 2015).