Drug Overpricing Complaints
Instructions: How to research drug over-pricing in plans sold on the healthcare marketplace and file a complaint
Below are instructions to help you research drug prices on the healthcare marketplace (www.healthcare.gov) and use the template to file a complaint with your state’s Bureau of Insurance and the U.S. Health and Human Services’ Civil Rights Office about health plan over-pricing of the hepatitis B antivirals Viread (tenofovir) and generic entecavir.
Who can file a complaint? Anyone can file a complaint at any time. You do not have to be a hepatitis B patient or a purchaser/holder of the insurance plan to file an administrative complaint with your state Bureau of Insurance or the federal civil rights office.
How do I file the complaint? Each state’s bureau of insurance website should have a portal for filing a complaint. Usually you can copy and paste the completed complaint into a complaint form at the website, or you can email the complaint to the insurance bureau.
To file the complaint with the HHS Services' Civil Rights Office, go tohttp://www.hhs.gov/civil-rights/filing-a-complaint/index.html and follow the instructions to file the complaint. We recommend you file the same complaint with both the insurance bureau and the federal government. Indicate in your state complaint that you are also filing the complaint with the HHS Civil Rights office.
How to research drug price “tiers” in your area’s health plans.
You will review only the Silver Plans sold on the marketplace, which are more common and qualify for subsidies for people with income below 250% of the federal poverty level. Follow the instructions below as you navigate the marketplace website.
1. Open www.healthcare.gov
2. Click on Get Coverage in the upper toolbar, located under theHealthCare.gov title.
3. Do not click on Select Your State, instead scroll down and click on See Plans & Prices - Preview 2016 plans.
4. Now, enter your zip code, and Choose your county or region that appears below it.
5. On the next few screens, click on “Skip.” Skip: household, are you married, tell us about yourself, expected household income, and the next Tell Us About Yourself screen. There will also be pop up screens to skip. Stop at the Review your information screen.
6. On the Review your information screen, click on Continue to Plans at the bottom.
7. On this screen, you are finally presented with the available health plans in your area, starting with Bronze Plans. In the left "Filters" column, under Plan category click on Silver Plans. Now you are presented with only the Silver Plans in your area. When we entered a Philadelphia zip code, for example, there were ten Silver Plans listed.
8. At the bottom of each plan’s summary, is a green Learn More About This Plan. Click on the Learn More button for detailed information about each Silver Plan.
9. This page provides detailed information about each plan’s monthly premiums, total deductible, and total out-of-pocket costs. This page also leads to what "Tier" it places tenofovir (Viread) and entecavir on and also how much you’ll be expected to pay for the drug each month.
9. On this page, scroll down to People Covered and Documents. You will find links to a list starting with Summary of Benefits. At the bottom is List of covered drugs. Click on List of covered drugs.
10. You will be led to the insurer’s drug formulary booklet, usually a .pdf file, or you may have to navigate through another screen to get to it, depending on the health plan. You’ll have to search by either drug name or by the category “antiviral” to find the tiers for each drug. Each insurer's drug list is different.Ultimately, you want to find Viread at 300 mg and generic entecavir at 0.5 mg and find out what Tier is assigned to the drug and whether it’s a preferred, nonpreferred, or specialty drug. You will use the "tier" rank to find out how much a patient will have to pay for the drug each month.
Example: When we researched Silver Plans in Philadelphia, the first plan reviewed was the Independence Blue Cross · Keystone HMO Silver Proactive Value Silver HMO | Plan ID: 33871PA0040007. It gave these rankings to the two antivirals:
- Viread a Tier 3 (preferred brand) ranking
- And generic entecavir a Tier 2 (nonpreferred, specialty product) ranking
11. Once you know the Tier ranking of the drug, you need to find out how much you are charged for that “tier” of drug. To find the cost, return to the plan's detail description page (reached on step 8 above.) Scroll down to the Documents list section again and this time click on Summary of Benefits.
12. This summary provides information about the scope of coverage, deductibles, and drug costs. This is usually a .pdf of a brochure. Scroll down to the section that describes drug coverage based on tiers to find out how much a customer would pay for a 30-day supply of each drug. The Independence Blue Cross · Keystone HMO plans we referred to above charged the following:
- Viread a tier 3 (preferred brand). A customer pays 50% of the cost of the drug for a 30-day supply, or a maximum of $400 per prescription. Viread costs around $1,000 a month so you would select the less expensive $400 per prescription per month to document as the plan’s monthly cost of Viread in your complaint.
- Generic entecavir a tier 2 (nonpreferred, specialty product). A customer pays 50% of the actual cost of generic entecavir or a maximum of $500 per prescription. The current retail price for generic entecavir is about $400 to $500 a month, so you would document the monthly cost of generic entecavir as about $200 to $250 under this plan.
This is the chart format we used to track health all available Silver Plan drug tiers and prices for a region. We inserted this chart, when it was completed, into our complaint.
Silver Plan Name
Drug Tier Ranking
Cost to consumer
Independence Blue Cross · Keystone HMO Silver Proactive Value Silver HMO | Plan ID: 33871PA0040007
Viread, Tier 3: 50% of the cost of the drug or a maximum of $400 per 30-day prescription.
Now, review all other Silver Plans and see what they charge for generic entecavir and Viread and copy them and summarize them in your complaint.
By documenting these “adverse pricing” tiers, you show how the drug formularies inflate the prices of even generic drugs to discourage people with pre-existing conditions -- in this case hepatitis B -- from purchasing the plans.
Often, each health insurer's drug formulary list is the same for all Silver Plans, which makes it easy to research. Unfortunately, you will still need to review and document each one to show the variations (and discriminatory over-charges) in pricing.
In the complaint template, we have included a second complaint about how difficult the marketplace’s interface is to use to find the actual cost of the drug, as you have just experienced first-hand. All insurance plans sold by the marketplace use this interface design. We hope next year the interface will be redesigned to make it easier to research drug prices for each plan.
Remember to email a copy of the complaint to your state's Bureau of Insurance and HHS Office of Civil Rights.