AFC, Howard Brown Health denounce IL Medicaid's removal of HIV drug from approved formulary

April 25, 2016

The AIDS Foundation of Chicago (AFC) and Howard Brown Health (HBH) have confirmed that the Illinois Department of Healthcare and Family Services (HFS) will remove Atripla from the preferred drug list beginning Monday, April 25, in an effort to reduce costs. 

Atripla was the only single-tablet regimen (STR) HIV medication covered under the Illinois Medicaid program’s preferred drug list. New patients enrolling in Fee-For-Service, administrated by the Medicaid program within HFS, will be denied access to any STR without undergoing the onerous prior authorization process. 

This complex approval method, which does not always guarantee coverage, unnecessarily restricts access to these life-saving medications and is inconsistent with federal HIV treatment standards. Additionally, recent studies have confirmed that early and continuous HIV treatment produces viral suppression, which is critical to keeping patients healthy, mitigates long-term complications and reduces new transmissions. Verification released by the National Institute of Health (NIH) demonstrates that consistent access to HIV medications reduces the chance HIV will be transmitted to others by 96 percent. AFC and HBH call on Gilead and ViiV Healthcare, who manufacture other first-line HIV treatments, to provide substantial discounts for Medicaid to ensure patients’ continued access to life-saving treatment.

“Not covering the newest HIV drugs under Medicaid, and restricting access to Atripla, denies highly vulnerable, low-income people with HIV access to the newest and most effective treatments,” explained Ramon Gardenhire, AIDS Foundation of Chicago’s vice president of policy and advocacy. “Increasing access to single-pill HIV medications will save Illinois money by reducing hospitalizations and improving overall health outcomes. It will also drastically improve the lives and productivity of people living with HIV, as well as reduce additional transmissions. We urge Medicaid to immediately cover HIV medications without bureaucratic prior authorization requirements.”

Other than the immediate ramifications the recent HFS decision will have on the patients they serve, additional, long-term costs to the state have been projected as a result.

“The state’s move to require prior authorization of Atripla, and not cover newer one-pill drugs, will actually raise overall health care costs,” explained Magda Houlberg, M.D., Howard Brown Health’s chief clinical officer. “One study showed that people with HIV taking a single pill were 24 percent less likely to be hospitalized than patients receiving three or more pills per day. Another found that single-pill HIV medications cut hospitalizations by 23 percent and overall healthcare costs by 17 percent.”

Significant advances have led to highly effective HIV treatment, including single-pill medications that revolutionized care a decade ago. STRs are among the best options for HIV medications when treatment is started and when medication adherence is a particular concern, as it is with many highly vulnerable Medicaid recipients.

There are currently six approved STRs from which providers may choose in customizing individual patient care for people living with HIV, including  Atripla, Complera, Genvoya, Odefsey, Stribild and Triumeq. Atripla, the oldest STR, is only listed as an “Alternative Regimen Option” in the guideline. However, refusing patient access to any STR on the Fee-For-Service preferred drug list will result in denying people living with HIV access to the approved life-saving therapies.

In addition to urging Gilead and Viiv to provide the suggested discounts to Medicaid subscribers, AFC and HBH urge advocates to contact Governor Bruce Rauner and demand that this decision be reconsidered.

Categorized under Advocacy and Illinois.

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