Hep B Blog

Help Stop Insurers from Over-Charging Patients for Hepatitis B Drugs on the Healthcare Marketplace

Image courtesy of Taoty at FreeDigitalPhotos.net
Image courtesy of Taoty at FreeDigitalPhotos.net

By Christine Kukka

For years, people with pre-existing conditions like chronic hepatitis B struggled to get health insurance. News stories and Michael Moore’s documentary Sicko highlighted insurance companies’ refusal to cover pre-existing conditions and their practice of inflating premium prices if consumers had chronic health problems.

Outraged by industry efforts to cover only low-cost, “healthy” consumers, lawmakers banned discrimination  against pre-existing conditions in the Affordable Care Act (ACA – Obamacare). The ACA’s Healthcare Marketplace website promises, “Your insurance company can’t turn you down or charge you more because of your pre-existing health or medical condition like asthma, back pain, diabetes, or cancer.”

While health plans sold on the marketplace can’t openly refuse to insure people with pre-existing conditions, some have devised an insidious way to discourage people with hepatitis B from buying their policies. They have dramatically increased the copays consumers pay out-of-pocket for the two leading hepatitis B antiviral drugs (Viread and generic entecavir) to deliberately make their health plans unaffordable for people with chronic hepatitis B.

When health insurers design plans, they assign each prescription drug a price “tier.” A low-cost generic antibiotic may be a Tier 1 while a new, brand-name drug is assigned a pricier Tier 4 or 5 ranking. A review of several Silver Plans sold on the marketplace shows entecavir and Viread (tenofovir) prices can reach up to $500 a month after the plan’s deductible is met. This deliberate over-pricing of certain drugs to deter people with chronic conditions from buying a health plan is called “adverse tiering” and it violates the ban against discriminating against pre-existing conditions.

healthcare.gov screen captureFor example, a survey of Silver Plans sold on the marketplace in one region found one company placed generic entecavir on a “specialty” Tier 4, which required consumers to pay a minimum of $200 to $300 a month for this vital medication. In contrast, a different company placed entecavir on a Tier 2 rank and charged a more modest $50 monthly copay.

According to legal and medical reports, these insurers’ drug tier designs and their discriminatory cost-sharing requirements deliberately discourage people who desperately medications from enrolling in their plans.

To fight these practices, The AIDS Institute and the National Health Law Program filed complaints in Florida against insurance companies that inflated their HIV drug prices through “adverse tiering” to discourage people living with HIV from buying their plans. At the time of the complaint, one insurance company, Humana, required patients to pay 50 percent of the drug’s retail price for HIV drugs after patients met a $1,500 deductible. The insurers were fined and the drug tiers for HIV drugs were revised to be more affordable, but this “adverse tiering” persists nationwide for hepatitis B and C drugs.

The Hepatitis B Foundation is working to change this discriminatory practice, but it needs your help to file complaints so your state and the federal government can investigate “adverse tiering” in plans sold in your region through the marketplace.

To file a complaint, an individual or organization needs to research Viread (tenofovir) or entecavir prices listed in all Silver Plans advertised in their region’s marketplace website to see if the drug costs are over-priced. People who file complaints don’t have to have hepatitis B, or even buy health plans on the marketplace.

The foundation, in collaboration with the National Health Law Program, has created instructions and a template for consumers and organizations to use to file complaints. Consumers will have to do some research on the marketplace’s website to discover the drug prices in their region, but they can help end discrimination and bring down the rapidly-escalating drug prices found in many health plans.

To review how to research and file a complaint click here. The instruction page provides a link to a template that you can fill in with your local information. For additional information, please contact the foundation at chris.kukka@hepb.org.

Even if you don’t file a complaint, if you shop for healthcare insurance on the marketplace, take time to thoroughly research how much the plan will charge for antivirals to protect your rights and your wallet.

Note: Federal laws that prohibit discrimination against pre-existing conditions apply only to Affordable Care Act health plans sold on the marketplace. If you purchase insurance through your employer, unfortunately there are not as many legal protections in place to prohibit adverse drug tiering. However, research your plan carefully, there may be cafeteria options that allow you to select the most advantageous plan for your treatment needs.



Comments on this blog are closed. If you have questions about hepatitis B or this blog post, please email info@hepb.org or call 215-489-4900.

6 thoughts on “Help Stop Insurers from Over-Charging Patients for Hepatitis B Drugs on the Healthcare Marketplace”

  1. I am a man 38 years
    on 10th February i got these lab results
    Liver Function Tests
    Total Bilirubin 0.30 mg/dL 0 – 1.2
    Direct Bilirubin 0.10 mg/dL 0 – 0.3
    Indirect Bilirubin 0.20 mg/dL 0 – 0.9
    SGPT (ALT) 27 U/L 0 – 49
    SGOT (AST) 27 U/L 0 – 34
    Kidney Function Tests
    Serum Creatinine 0.9 mg/dL 0.7 – 1.3
    Blood Urea 22 mg/dL 10 – 45
    Serum Uric Acid 4.60 mg/dL 3.0 – 7.0
    Hepatitis Markers
    Hepatitis B surface antigen Positive
    Hepatitis B e antigen Negative
    Hepatitis B e antibody Positive
    HBV DNA Quantitative by (TaqMan) 32648 IumL < 20
    FibroScan with 7.4 KPA F2

    and i went to liver specialist yesterday and he advice me with
    check liver biopsy to talk the correct decision for treatment "for ever" or not "just monitor the liver "
    today i get Live pathology report

    liver Pathology report

    Length of the core : 2 CM
    Number of portal tracts : 9
    Degree on interface hepatitis : Mild
    Degree lobular necrosis : Mild
    Degree of portal inflammation : Mild
    Stage of fibrosis : Mild
    Degree steatosis : No
    presence of cirrhosis : –
    Presence of dysplasia : –
    Presence of malignancy : –

    Mild chronic Hepatotos B
    Mild Fibrosous portal expansion without septa
    No Steatosis
    ISHAK Score : 4/18 Stage 1/6
    Metavir score : A1,F1

    I went to my doctor and his device to monitor every six months with these alt,ast,pcr,alfa fetoprotien and HBsag
    and i asked you before and your reply matched with my Liver sprcialist
    On 8th Mar 2016 i did absag is positive and hbs AB negative with 2 miu/ml whats are
    now I am terrible from my Liver Damage and every day i thinking more about my
    HBV infections
    1- what your advice to me to check with another Liver specialist
    2- and about the future cure i read about ARC 520 and ABX203 they on Phase 2 and from their companies may be will be around 2020 and i don not how i can wait until 2020 without my Liver damage
    3- also i have HBeag negative and HBe AB positive this means the i infected with mutant HBV or the HBV got mutant in my body
    4- my HBS AB=2 miu/ml and i get a healthy life style and healthy foods if this HBS AB increased it is a good this thing or may HBSag get mutant for this HBS AB
    5- how many years estimated to my HBV to damage my liver
    please answer me and thanks in advance

    1. Hello: Your doctor is giving you good advice, you have mild inflammation in your liver, however your ALT level is within the normal range, so currently there is not extensive liver damage occurring. I think you are in good hands, as your doctor indicated, you need to be monitored every few months particular for your ALT level and viral load. Your immune system is trying to fight the infection, which is a good sign. You are receiving good care, if your ALT levels increase and you need treatment, there are two very good antivirals (tenofovir and entecavir) available. Please do not worry. Continue your healthy lifestyle, avoid alcohol and cigarettes and get monitored regularly and you will be fine.
      There are many new drugs in development, and experts predict a cure should be developed in the next few years. Be positive, your have a bright future. Good luck.

  2. Hi,
    could you please tell me that under what condition a (chronic infection hep b) patient should be ordered for liver fibroscan or Pathology? Thanks.

    1. Hello: Current medical guidelines recommend there should be at least a baseline ultrasound performed to use as a reference. If you have experienced liver damage (and had elevated ALT – liver enzymes), have a high viral load or have a family member who has had liver cancer, you should get screened regularly using a Fibroscan or ultrasound. For more information about liver cancer screening, please see: http://hepbblog.org/2015/10/21/want-to-avoid-liver-cancer-there-are-things-we-can-control/
      Good luck.

  3. Hi, the article “Help Stop Insurers from Over-Charging Patients for Hepatitis B Drugs…” is very encouraging. I have HepB and have been on Entecavir for 5 years. I’m covered by Medicare. My drug insurance is offered by Cigna under Medicare. This year Cigna gave me hard time about my Entecavir copay. First they changed the tier of Entecavir to dramatically increase my copay. After working with a Medicare designated 3rd party agent, I convinced Cigna to adjust down the tier for Entecavir. But 2 months later, with only 2 prescription purchase this year, I was told by Cigna that I have reached “donut hole” of their plan, so now I need to pay about $1,700 out-of-pocket to get a 90-day supply of Entecavir. Cigna said this is to blame the pharmaceutical company who had raised Entecavir price over 10 times in 2017. I want to ask you if it is true that Entecavir price had increased so dramatically by the turn of the year? If so, why? To my understanding, Entecavir is a generic drug, isn’t it? What I experienced was really astounding. Where can I voice my confusion and frustration? I would appreciate your insight about what is the best channel for me to report this price gauging and the senseless encounter with insurance? Your help would be much appreciated!

    1. Hello: Entecavir is now a generic drug and should not be experiencing price increases. I am sorry you are experiencing this. I would recommend you contact the National Health Law Program (NHeLP), a non-profit organization dedicated to ensuring health care rights for those in need. They have been helpful in suing insurers who over-charge for HIV and viral hepatitis drugs, and may be able to help. Their phone number in Washington DC is (202) 289-7661 and its website is: http://www.healthlaw.org/
      Good luck.

Comments are closed.