This webpage compiles resources to help medical providers address and report coverage issues. Please contact us with questions.
File an Exceptions Request or an Appeal
The Patient Protection and Affordable Care Act enacted new protections for consumers. This fact sheet provides information to assist HIV medical providers with challenging health plan’s adverse coverage decisions.
Report Issues with Private Health Plan Coverage of Antiretroviral Drugs
State offices of insurance offices play an important role ensuring that health insurers are meeting minimum state and federal coverage requirements.
Providers should report health plans that are not covering antiretroviral drugs; plans charging extremely high cost sharing for antiretroviral drugs or plans requiring prior authorization for all or most antiretroviral drugs.
Providers also should report health plans that refuse to contract with them or that have unreasonable contracting requirements.
Report Issues with Medicaid Coverage of Antiretroviral Drugs
State Medicaid programs that offer prescription drug coverage are required to cover most FDA approved prescription drugs. However, Medicaid programs can restrict access by creating preferred drug lists or using other techniques. Some state Medicaid programs are restricting access to antiretroviral drugs or considering restrictions.
In 2015, HIVMA members in Georgia successfully intervened when the state was considering placing single tablet regimens on the non-preferred drug list. Read the letter HIVMA sent to the Georgia Medicaid director on this issue. HIVMA also wrote to Gilead Sciences and ViiV Healthcare urging them to negotiate drug discounts and rebates with state Medicaid programs.
If your state is restricting access to antiretroviral drugs: