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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 increase
the 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 legislature should 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 the
Access to Medications in South Carolina
Reducing Barriers to Care and Treatment for People Living with HIV
apparent 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 Act
has 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,
http://www.hrsa.gov/opa/index.html.
8 Nat’l Association of Community Health Centers, Benefits
of the 340B Drug Pricing Program for Health Centers
(2011),
https://www.tachc.org/content/5.11_NACHC_study_on_3
40B_benefits.pdf.
9 S.C. H 3159, Pharmacy Patient Protection Act (Introduced
Jan. 13, 2015).