A health insurance provider recently denied HIV medication to a New York man after accusing him of “engaging in high-risk homosexual behavior.”
The letter was sent by United HealthCare, an insurance provider based in Minnetonka, MN, and was posted in a Facebook group for HIV/AIDS awareness.
“This decision is based on health plan criteria for Truvada,” it reads. “The information sent in shows you are using this medicine for engaging in high risk homosexual behavior.”
Say what?!
How about we take this to the next level?
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Related: Insurance Company Slut Shames Man, Denies Him Coverage Because He’s On Truvada
The letter goes on to explain the man’s policy only covers Truvada if it’s being used to treat HIV infection, to reduce the risk after possible HIV exposure, or to reduce the risk of potential HIV exposure for certain “high-risk” patients.
For whatever reason, the company determined, he did not meet any of those criteria.
Truvada is currently taken by approximately 100,000 patients across the U.S. and has been proven to reduce the risk of HIV infection by 99 percent. Without insurance, it can cost a person up to $1,500 a month out of pocket.
“This was a malicious attempt to discourage PrEP (pre-exposure prophylaxis) uptake by people who need it most,” Jeremiah Johnson of the Treatment Action Group tells Raw Story.
Related: Republicans plan to jack up the price of PrEP because, hey, who needs HIV/AIDS prevention anyway?
Johnson went on to explain that the man appealed the coverage denial, and, after a lengthly back and forth, ultimately got the insurance provider to pay for his drugs, but the experience highlights one of the many hurdles people face when trying to access the medicine.
Patients must also order the drug online and have it delivered by mail, which Johnson says raises privacy concerns. It also requires a complicated medical report be filed four times a year by a patient’s physician.
“This is an enormous barrier for some people,” he says
United HealthCare has declined to comment on the matter.
KaiserVonScheiss
One of the main reasons prescriptions are so expensive is because insurance pays for it in the first place. This gives pharmaceutical companies bargaining power they otherwise wouldn’t have (it’s the same with doctors’ offices).
The solution is to move away from comprehensive health insurance, an unsustainable model, and towards so-called “catastrophic”/high deductible plans. Insurance is for catastrophic or tragic events, not for things that are routine.
Imagine if you car insurance had to cover oil changes, brake lights, tail lights, head lights, tire rotations, etc — all of these things would be more expensive and your insurance premium would go through the roof. This is what’s happened with health insurance.
As for this particular incident, if the policy says X, then it should be X. I know it might suck, but that’s the way it is. Of course, if insurance weren’t involved at all, then the prices would fall significantly.
Creamsicle
That is an awful suggestion. If insurance only covered “catastrophic” situations then there would be far more people delaying preventative care and screenings. Fewer people seeing and paying for general practitioner visits would lead to more cases that would be considered “catastrophic,” and the result is that insurance premiums would increase due to having a more concentrated pool of people who need extremely expensive treatments and procedures.
That’s the whole reason why the ACA included an insurance mandate. Insurance providers knew that if insurance wasn’t mandated then people would wait until they were sick to buy into the system, and they would no longer be able to deny ote-existing conditions or impose lifetime spending caps.
Your “catastrophic coverage only,” suggestion also means that there would be even less incentive for doctors to become GPs. The US already has a lack of new GPs because becoming a specialist is pays so much better, and that’s with the bloated costs that we’re paying now.
KaiserVonScheiss
No, they would pay for it out of pocket. Doctors would have no choice but to lower their prices. Customers would shop around for medical services.
Also, under many catastrophic plans, preventative care is often still covered, depending on the plan.
Under Obamacare, long-term catastrophic plans are only for low-income individuals or are otherwise only available for a three month period.
DarkZephyr
What about in situations where its not immediately recognized as “catastrophic”? I recently spent 2 weeks in the hospital with something that didn’t seem very dangerous at first. The only reason I wanted a hospital bed was to help with the pain. I am a working, tax paying citizen but I was unable to afford health insurance before the ACA. The ONLY reason I got that bed was because of my coverage. WHILE I was there it was discovered I was close to death and needed intensive treatment to save my life which I then got. If what you suggest had been the norm, I would be dead or nearly there. Instead I am alive and my health is back to normal. Thank god for Obamacare.
KaiserVonScheiss
@DarkZephyr
“Catastrophic” doesn’t mean only what insurers deem to be “catastrophic”. They are only high deductible plans. They are called “catastrophic” because it’s unlikely you’re going to go through your deductible with a primary care physician. Thus, they are most likely to be used with emergencies, like hospitals, etc.
It would be covered AFTER your deductible. How much is covered (co-insurance) would depend on your plan.
Catastrophic plans would have much lower premiums.
I, too, used the Obamacare. I needed testing related to my mental health. Had insurance not been necessary, the cost would have been much lower. I wound up paying $550 out of pocket. That doesn’t include the $300 insurance premium I paid.
The system is so bad, they wouldn’t even see me without insurance. They would always give me the run-around and say they’d call back, but they never would. But the second you have insurance, fine. They like the insurance system because make more money that way.
I also support health insurance co-ops, which is something that would lower premiums even more because the insurance plans would actually be owned by the insured, not the insurance companies.
dwes09
You clearly do not understand the difference between liability/theft etc for automobiles, and health care coverage. Not surprised at all. If you know how to think, and have a memory, think back to the hobby lobby idiocy. The providers in that case chose to provide prophylaxis to subscribers regardless of hobby lobby’s regressive agenda. Why? Because prevention of pregnancy is a heck of a lot cheaper than pre and neo natal care or the complications not uncommon in pregnancy. So too the provision of PrEP has proven less expensive than the maintenance of subscribers with active HIV infections over the long term.
And it is clear from the wording of the letter (with glaring internal contradictions) that the reason for refusal was based on distaste for homosexuals. It is always cheaper for health care providers to maintain health than to treat acute or chronic conditions. That is true regardless of the libertarian fantasies you harbor.
jsmu
KOPF von Scheiss–You’ve been mortified by three different commenters here. Your Ayn Rand jagoff was tried, remember? The bad old days of endless deductibles, preexisting conditions, and tens of millions who could never even get, much less afford, any health insurance–even the shitshows the companies were foisting on the public. Your idiotic use of ‘THE Obamacare’ (it’s called the Affordable Care Act, imbecile, and was christened ‘Obamacare’ by racist Rethugs in order to whip up their n*gger-hating base into a frenzy because that BLACK man in the White House.) says it all.
KaiserVonScheiss
@dwes09
Insurance is insurance. Regardless of type, the purpose is the same: to mitigate financial risk do to catastrophic or tragic events.
High deductibles mean the insurance will be used for emergencies. This will drive down costs of both insurance premiums and medical services.
Comprehensive insurance means people are less likely to shop around for doctors and other service providers. It also increases the demand for services because the main payer is the insurance company, not the patient. Ultimately, the payer (generally the insurance company) is willing and able to pay more (which is compensate with higher and higher premiums). Comprehensive insurance effectively serves as a private demand subsidy for routine health services, driving up the price.
When demand increases, ceteris paribus, the price goes up. This is what happens for routine health insurance.
@Jsmu
Sorry, no, I don’t remember any Ayn Randian health care system.
ChrisK
I guess they consider being gay a pre existing condition.
barkomatic
I hope this type of action by insurers doesn’t become routine. To deny coverage for a treatment that is explicitly intended to prevent HIV transmission in high risk situations is obviously outrageous. However, if it means profit, the pharmaceutical industry has proven over and over again that they are more than willing to commit outrageous abuses.
ChrisK
Business is driven by quarterly profits. Not long range planning.
John
What is a “high risk homosexual?” Are we all at risk for STDs, regardless if we are safe and monogamous or risky and promiscuous? It can happen to anyone. If someone wants to take control of their health, they shouldn’t be slut shamed.
Chris
I think that some under-educated drone denied coverage without realizing that Truvada is intended to mitigate the risks of seroconverting due to certain “high-risk” behaviors. The reason given for his being denied fits one of their criteria like paint on a wall. I’d appeal.
Paco
Would the insurance rather pay for multiple HIV drugs because they denied him one drug to keep him from getting infected?
Larry
This is normal almost for EVERY prescription. It’s always 3 times more if you don’t do mail order. Now not covering Prep is absurd but again it’s a FOR PROFIT health insurance company. Profit is their business, not healthcare.
ryuichi
I agree and I’m a Professor of Medicine at one of this country’s great med schools. We need a single-party (not for profit) payer system and to end the lives of the (for profit) health insurance companies. You are so correct “profit is their business, not healthcare.” I’ve met more than a hundred physician-reviewers who work for health insurers and it’s clear why they have those jobs, instead of seeing patients and/or teaching medicine.
dwes09
I found the subject of the article’s concern about privacy to be odd. Mail order drugs arrive in unmarked packages, they do not say “here is your truvada”. By contrast, pick-up at a pharmacy is much more likely to allow strangers and acquaintances to see the nature of the drugs you are picking up, and open up up to judgment and disdain from the small minded. Plus, you never have to remember to stop by the pharmacy.
KaiserVonScheiss
Even if one supports a public health insurance system, I don’t understand why someone would support single-payer.
Single-payer requires government rationing of care and wait times.
France has a social insurance system (not-single-payer) and is one of the best in the world.
fumey
It can be defended that homos are at high risk because the FDA states they can’t even donate blood if they had sex with another male. So there u have it, across the board all homos are high risk and should be able to obtain Truvada easily in the USA.
http://www.redcrossblood.org/donating-blood/lgbtq-donors
Brian
I’ve been trying to get this medicine for about 5 years. I had it for one 8-month stint, but not for the rest of that time. Health care in the US is a wreck!
sydboy007
If insurance in the USA covers truvada at $1500 a month or $18,000 per year, how does that impact premiums?
KaiserVonScheiss
It makes them more expensive, obviously.
Bromancer7
It doesn’t, because it’s a drop in the bucket compared to the costs of other drugs that are used by millions of people. And we also know that what the insurance company pays is far less than what a consumer would pay, so it’s not even close to $1500/month. Probably half that, if not less.
KaiserVonScheiss
All potential costs are factored into determining the premium. The more stuff covered, the more risk the policy will be used, therefore the higher the premium.
Dymension
Look, I’m all for you using PReP if you want for engaging in “high-risk” sexual activity. After all, if it weren’t high-risk, you wouldn’t be asking for it. However, does Jeremiah Johnson really need to say “the people who need it the most”? No. The people who need it the most are the ones who have HIV infection. If you are using it as a preventative measure, you don’t NEED it. You WANT it.
You could always choose safer sex. Jus sayin…
Bromancer7
And if you don’t enjoy sex with a condom, then what? Just suck it up and be miserable? Who are you to decide what someone does and doesn’t need in their lives? Jus sayin…
surreal33
I am amazed by the glaring hypocrisy of this situation and the comments.
A gay man in NYC seeks prep and a vast majority of comments are denying that the prep will be used to facilitate reckless, depraved, sex! Mr Johnson has a right to engage in whatever kind of sex he prefers. Mr Johnson should realize that insurance companies and the general public are not stupid we know exactly what you are doing. Insurance companies are all about mitigating risk not enabling self-destructive queens.
Bromancer7
The only hypocrisy, other than your blatant slut shaming, is that the stated reason for denial is exactly the same as one of the stated prerequisites for coverage. Did you even bother to read, or just jump to the “add your comment” section and start slut shaming?
mc4bbs
I have a friend who works for United Healthcare. I asked him the same question yesterday and he agrees that UHC would NOT deny this prescription irrespective of the employer — also, the letter has unusual phrasing and capitalisation, leading me to believe this is not accurate. Further research is required.
John
My issue is not solely with the insurance company but with the pharmaceutical company and with Johnson too.
Johnson has some responsibility to protect his health and not necessarily look to some company (insurance) to take on the full responsibility of that. Then the pharmaceutical company also expects the insurance to pay so they have reached deeply into what is seen as endless pockets of the insurance company, so it is overpriced. I am tired of seeing guys who boast “I am an Truvada” and then bend over at sex parties, bath houses etc allowing anyone and who everyone to pop a nut in them. That is not slut shaming that is acting irresponsible and uneducated. What is the long term affects of using Truvada? HIV has many strains and is constantly evolving, so what prevents (and treats) today may not in 5-10-15 years. Just like an antibiotic your body may or may build up a resistance then what are you going to do/say? lawsuit, I was on Truvada, it is supposed to prevent. What are the long term affects on your body? They check your liver and kidney function for some reason before allowing you to get the prescription, is it going to affect those functions later? are you sure? big pharma is all about getting a customer and advertising for beat all end all. They make “treatments” not “cures”…
surreal33
Thank you, for speaking truth to power. Sadly there is more than few gay men who prefer to bask in a fantasy world. In their alternate reality just pop a pill and like magic, you have no responsibility for your sexual choices. If you dare challenge said self-destructive, toxic, gay men you are slut shaming. Well, I am calling bullshit! If you are a dirty, irresponsible, selfish, pig engaging in sexual activity that you know can spread disease YOU SHOULD BE ASHAMED!!! Yes I and everyone has a right to judge when your depraved behavior jeopardizes the health and safety of other people.
scooter12
This letter is FAKE. I can tell you 100% it is fake. Insurance companies have a drug formulary. It lists in detail which drugs are covered and which drugs are not covered for each plan. It is either covered, or it isn’t. Since the only use of this drug is for HIV prevention, if the drug wasn’t covered, the prescribing doctor would know that by simply looking up the drug in the drug formulary (like they do for any drug). If there was a denial letter, it would be because the drug was simply not covered according to the drug formulary- not because of the way it would be utilized. This is obviously some attempt a grabbing attention.
woodroad34
I’ve had United Health through work…it’s the cheapest, least consumer friendly insurance around next to Aetna. Might as well be on Obamacare.