An Equality Florida member told us last week that his health insurer had denied coverage for an HIV medication he has taken for several years. He ultimately did get his meds, but he worried that the hurdles he faced might signal an effort by the insurance company to encourage HIV-positive clients to find another carrier.
We reached out to Florida Blue and the company acknowledged and apologized for a technical glitch that had affected 89 policyholders. It also issued this statement clarifying their policy.
Statement by Florida Blue:
Last year, the U.S. Department of Health and Human Services found in an investigation that Medicare spent more than $30 million in 2012 on questionable HIV medication costs and singled out Miami as the worst market in the country for potentially fraudulent activity. Because of this, both the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) have communicated their expectations that insurance companies would increase efforts to reduce such fraud, waste and abuse. President Obama reiterated this sentiment during his speech in West Virginia on Oct. 21.
To help address this issue, on Oct. 1, Florida Blue introduced an authorization program designed to reduce fraud and misuse related to pharmaceuticals associated with HIV therapies and treatments. The authorization program is similar to several other programs Florida Blue currently has in place for the treatment of conditions such as Multiple Sclerosis and cancer.
Under the new program, if a Florida Blue member receives a new diagnosis of HIV, the treating physician will confirm the diagnosis by providing lab results. New Florida Blue members who previously received HIV medication coverage through another plan also will have their diagnosis confirmed upon switching to Florida Blue. After the initial confirmation by the treating physician, no further confirmation will be required for ongoing treatment with the medication. Medicaid also uses a prior authorization program to help ensure appropriate utilization and improved member safety.
The new program does not affect any Florida Blue members currently receiving HIV therapies and treatments. All current members are grandfathered into the program, and no additional information is required from their physicians to continue their current treatments.
After implementing the program, a technical error was discovered in the claims system that resulted in 89 members being excluded from the grandfathering process. This resulted in two known members receiving denials for refills of their HIV medication. As soon as Florida Blue became aware of the error, it was immediately addressed and corrected. All impacted members were contacted and medications were overnighted to those whose refills were denied at no additional expense to them to avoid any lapse in medication.
We apologize for this error. Members who have questions can contact Florida Blue by calling the toll-free number on the back of their member ID cards, as all customer service representatives have been made aware of the issue. If Florida Blue members received a letter about their HIV medication, please call the toll-free number in the letter for additional details.
Florida Blue is committed to the health and wellbeing of all its members. It is our goal to ensure all our members receive the proper treatment prescribed by their physicians. Florida Blue continually reviews all authorization programs to ensure they are accomplishing the intended goals. If an authorization program is not accomplishing its goals, and instead is impeding treatment, we will either change that program or remove it.