TALLAHASSEE, Fla. -- Florida is poised to enact health care legislation that would add clarity to existing state statutes by requiring that all state-regulated health plans include lifesaving antiretroviral (ARV) HIV/AIDS drugs on their drug formularies or preferred drug lists. The bills, House Bill 591 by Representative Yolly Roberson (D-North Miami Beach) and SB 1132 by Senator Eleanor Sobel (D-Hallandale Beach), were introduced at the request of AIDS Healthcare Foundation (AHF), which serves more than 15,000 Floridians living with HIV/AIDS through a variety of programs, including free HIV testing and prevention programs; HIV/AIDS health care centers located in Ft.
“HB 591 and SB 1132 represent a prudent public health measure that will protect Florida patients by ensuring access to lifesaving HIV/AIDS drugs as prescribed by their doctor or medical provider,” said Michael Kahane, Bureau Chief, Southern Region for AIDS Healthcare Foundation. “The bill will level the playing field among all health insurance providers and health plans operating in Florida by clarifying existing state statute to specifically mandate that all state-regulated health plans operating in Florida include antiretroviral drugs on their drug formulary or preferred drug list. HB 591 prohibits health plans from restricting access to ARVs by requiring prior authorization, step therapy, or instituting any other limitation that would limit patient access. Medicaid health plans, private health insurance plans and health maintenance organizations all will be required to comply with the provisions of this bill. The patient’s doctor will be able to make the decision on what medications are appropriate instead of an insurance company – which is the way it should be.”
Need for the Legislation
AHF, which treats thousands of patients at its healthcare centers in Florida, Washington, DC and California, first proposed the legislation to Representative Roberson after some Florida HIV/AIDS patients with private insurance encountered difficulties accessing the lifesaving ARVs their medical providers had prescribed. The patients encountered situations where a health plan’s formulary may include some, but not all FDA-approved ARVs; where the plan limits the number of ARVs that will be reimbursed (for example: the physician has ordered a regimen that consists of five ARVs, but the plan indicates it will only cover four); and at least one plan that has no ARVs on its formulary whatsoever.
AHF and its patients found that some insurers and health plans in Florida cover the medications without delay. However, some make routine practice of denying claims, or requiring lengthy procedures to authorize payment for—or access to—ARVs, practices that have often resulted in multiple week delays for patients to obtain the needed medications.
“To date, AHF medical providers have successfully reversed every denial of coverage, suggesting that this industry practice of denial is not an issue of inappropriate utilization or prescribing practices by physicians, but is a matter of purposeful delay that is intended, we believe, to avoid paying for crucial lifesaving services that these patients have contracted and paid for through the purchase of their insurance coverage," said Rebecca Colon, Medical Director of AHF NorthPoint Healthcare Center in Ft. Lauderdale. “The claims that are being delayed result in breaks in treatment that can be life-threatening to the patient. When a patient receives an ARV different from what is prescribed, or has a multi-week delay in starting or changing a specific treatment regimen, the patient is at risk of developing resistance to the prescribed ARVs that can result in the need for a different, more complex regimen in order to be effective. Frequently, these newer drugs are more costly, so the delaying tactic is ultimately short sighted. The delay in receiving the proper treatment also results in a public health concern as the virus is more likely to be transmitted when a person is not taking proper medications."