BlueCross BlueShield begins new discrimination against cancer and HIV patients

It’s called adverse tiering. It’s been reported on in outlets from the New England Journal of Medicine to the New York Times.

It’s the new way health insurance companies are trying to discriminate against "costly" patients and push those patients off their plans.

And it has arrived with a vengance in North Carolina.

Last week, BlueCross BlueShield of NC sent thousands of letters to cancer and HIV patients in North Carolina telling them that their medications will be moved to the highest (most costly) tier of their prescription medication formularies.

Approximately 36 cancer drugs and approximately 32 HIV drugs -- drugs that have no generic alternatives -- will skyrocket out of reach of existing patients. The cancer medications on the adverse tiering list include treatments for ovarian cancer, breast cancer, colon cancer, prostate cancer, leukemia (blood cancer), lymphomas, lung cancer, testicle cancer, intestinal cancer, and on and on.

There is a bit of a new twist in the BlueCross adverse tiering situation in NC that is different from previous reports and studies on adverse tiering in other states. This isn't just happening to small group plans or individuals purchasing insurance on the ACA (Obamacare) exchange. Even if you’re on an employer-based insurance plan in a large pool, BlueCross is jacking up your prescription tier to the most costly level to push you off of their books.

In one example from BlueCross' adversely tiered cancer and HIV medication list in NC, a person on a silver level comparable ACA plan paying a $45 monthly ($540 annually) co-pay for one prescription will now pay almost $7000 annually for the same medication -- an over 1200% increase to absorb in just a few months -- for just one medication!

This new discrimination has been rolled back by other insurance companies (Cigna, CoventryOne, Humana, etc) in other jurisdictions like Florida and Washington, DC.

This does not have to happen in NC. This was rolled back in other states.

Adverse tiering is simply a ploy to push some costs off the books of the virtual health insurance monopoly which is the "non-profit" BlueCross BlueShield of NC.

BlueCross BlueShield of NC should roll back this abhorrent practice against cancer and HIV patients.

Mainstream and social media need to shine a bright light on this. If you know a cancer or HIV patient who got that letter, tell them to take it to the local newspaper or TV station.

Regulators from the federal Dept of Health and Human Services (Office of Civil Rights) down to state level regulators need to get ahead of this before it begins to impact treatment on patients in NC.

Health advocacy organizations for cancer and HIV patients need take this on immediately. It is a winnable, worthwhile and just fight



Google Adverse Tiering

For more context on the studies of this practice and how it was rolled back in other states, just google Adverse Tiering


Would bringing this to the attention

of Wayne Goodwin perhaps facilitate NC insurance companies' rejection of this type of discrimination?

It seems like this would violate state regs somehow/somewhere...

Adverse tiering does violate new regulations from the US DHHS

Adverse tiering does violate a new regulation recently finalized by the US Dept of Health and Human Services.

However, DHHS needs to be made aware that BlueCross BlueShield of NC is doing this so they can take corrective action.

Getting this to the attention of Wayne Goodwin, Roy Cooper and even the chairs of the legislature's health and health appropriations committees would be good.

Adverse tiering will impact state and municipal governments directly through the insurance plans themselves and indirectly through the costs of taking care of people who were paying for their own health care who will no longer be able to afford it.


I dropped a link

to this diary on Wayne's Facebook page. He may have already seen it since he reads BlueNC (and occasionally blogs here), but it may take some time before he notices my comment.

Thanks for the push against adverse tiering

Some of this is relatively new -- as you can see from some of the linked article dates.

It's a shame it has to be on our radar in NC.

BCBSNC already has a virtual monopoly here.

Kicking cancer and HIV patients in their teeth is beyond the pale.


Message from Commissioner Goodwin

via Facebook comment:

Wayne Goodwin Thank you, Steve -- I saw that post this AM and directed my team this AM to look into this. If I had not seen it then your message would have prompted me to act as well. Again, Thank you.


Just want folks to know this matter is still active and very high on my radar. At my direction my team continues to look into the matter. Many thanks to BlueNC for bringing this to my attention! Vigilant consumer protection requires all of us to work together and report concerns to each other.

Thank you -- BlueCross BlueShield's timing was deliberate

The adverse tiering letters were dated and mailed at the end of August to hit (their hoped future non-) customers at the beginning of September -- just in time for people to be forced to "coincidientally and unfortunately" to investigate other providers before October 1.

Of course, BCBSNC is already the dominant provider in the state with no need to claim more market share in NC.

Here's a link to the US Dept of Health and Human Services Office of Civil Rights.

If folks want to direct people to file complaints there and get the feds on BlueCross BlueShield too, be my guest.


Adverse Tiering in NC makes The N&O

In an article about Affordable Care Act premium increases, BlueCross BlueShield's discriminatory (and likely illegal -- wait for the first federal lawsuit forthcoming in the district) adverse tiering policy against cancer and HIV patients is acknowledged with a number.

Insurers are also moving quickly to manage their costs. Blue Cross, the state’s largest health insurer, which lost $50.6 million last year on its ACA line of business, is moving specialty medications for HIV and cancer into the highest cost category. This move, affecting about 650 Blue Cross customers statewide, will raise patients’ medication bills from several hundred dollars this year to potentially thousands of dollars next year for the same treatments.

What is implied in the article is that this is just impacting cancer and HIV patients only on ACA plans. In fact, Blue Cross Blue Shield's adverse tiering is also being implemented to covered individuals ON EMPLOYER PLANS.

So this is impacting more than the 650 people approximation in the article -- and it can't be blamed on the ACA.

BCBS is doing this to other cancer and HIV patients in the state -- and they can be sued for it.

It is my hope that since Commissioner of Insurance Wayne Goodwin hasn't gotten back to us yet, cancer and HIV patients contact lawyers and file suit against BCBS in federal court.

Here's the roadmap for your lawyers.


Update to my Sept 3rd post

First of all, thanks for everyone's patience with my team and me in getting back with you. A significant part of the delay is that the nature of the issue required special review by several experts, as well as a thorough review by my NCDOI team and a back-and-forth, as required, between my office and the company. I also had to await feedback on whether any of the information we obtained was, by current long-standing law, non-public for any reason.

Second, I indicated very recently here on BlueNC in James's request for an update, that one would be forthcoming from me. A very rough overview had come in a few days ago but it needed clarification and shortening. Having just returned from my meeting of the National Association of Insurance Commissioners in Washington, DC, and noting the current post, I am providing the answer as best as possible at this point so there's no further delay. I may be able to provide a more succinct summary after returning to my office tomorrow.

Third, it is important to note that every Blue Cross Blue Shield is a stand-alone entity from other Blue Cross entities across the country. They do share a national association of their own, though.

Fourth, remember that insurance policies are ultimately contracts that, for consumer protection, must abide by state and federal laws.

Fifth, please note that today's post on BlueNC referencing the specific subject from a state/national standpoint (and in a new article in the N&O this weekend) may or may not contain new information we did not have during our review of the very serious question posed that prompted my initial inquiry for your BlueNC readers. So, accordingly, I respectfully reserve the right to amend the answer below.

So, here's what I understand about the original matter:

Based upon a lengthy review and based upon what I understand, on information and belief, is not protected from public disclosure, the change appears to be allowed under the insurance product. Also, BCBSNC has informed DOI that the company's change may affect approximately 650 insured members in NC. (That number also appears in the N&O article.)

I have also learned that the change in the tier for certain HIV and Cancer drugs to the higher cost share tier 5 at BCBSNC is applicable to the group and individual Blue Advantage product for drug prescriptions as of January 1, 2016. This opportunity for drug tier realignment is authorized in the Blue Advantage approved product language, which indicates that the action, as understood, is not prohibited. The change also brings the Blue Advantage Rx benefit into line with the currently marketed Blue Value and Blue Select plans.

My Deputy Commissioner with detailed knowledge of this complex matter states that Blue Cross Blue Shield of NC clarified that while it was true the company did make changes as indicated, NCDOI understands that insured members still had low cost options that were clinically proven just as effective as those moved to the higher cost share Tier 5. The change in drug Tiers for certain HIV and cancer treatment drugs from the lower cost Tier 1 to the specialty non-preferred drug Tier 5 was made due to their high prices and high utilization where lower cost alternatives were available. The move left in Tier 1 six different drugs in generic form for HIV treatment and 9 cancer generic drugs that are cost effective. The article which brought this to our attention gave the indication that all drugs of HIV and cancer treatments were removed from Tier 1.

The Blue Cross products have five prescription drug Tiers. Tier 1 is the lowest cost and contains the preferred generic drugs or prescriptions. Tier 2 is non-generic drugs. Tier 3 is preferred brand name drugs. Tier 4 is non preferred brand names and preferred specialty drugs; Tier 5 is the specialty drugs and non-preferred.

BCBSNC does not exclude the prescriptions that they cover but only determine the tier of which they apply the benefit for the specific prescription. Based on the information reviewed, and assuming that there are not additional facts that we learn later in this and related processes, it appears BCBSNC has acted within the insurance product constraints. (Ultimately any issue involving a contract is subject to interpretation by a court.)

Again, everything I have said is subject to revision, rescission, update, clarification, or further review if additional information is learned from readers, consumers, agents, BCBSNC and/or other entities.

You know me: If there's a problem my team and I will do whatever we are able to do to protect consumers. Perhaps many BlueNC readers recall my direct order that resulted in BCBSNC rebating a historic $156 Million to 215,000 NC families in 2010, a move that prompted national acclaim from consumers in NC, from consumer protection groups nationally, and even from the White House.

I greatly appreciate the original question and hope that folks will email me at with more direct questions or concerns, or, if a complaint against the company is in order, please go to the Consumer Services Division of or call my Consumer Services Division toll-free at 855-408-1212. As I'm sure you'd agree, to protect the personal medical privacy of consumers, I encourage individuals with specific personal medical concerns on this and similar subjects to contact NCDOI or the consumer's doctor or lawyer instead of comments on the Internet.

Thank you again for BlueNC's fight for NC consumers and good government! I will continue my similar vigilant fight.

Little out of my depth here

Actually, a lot out of my depth, but maybe these observations will spur comments from somebody who isn't:

While there are a lot of good generics in the lower Tier anti-retroviral category, it doesn't automatically follow that all patients respond well to these drugs. Many HIV patients are (or have become) resistant to older generics, while others haven't.

When it costs one person a relatively small amount to secure life-saving treatment and another tens of thousands annually, for the very same affliction, the fine print of an insurance company's contract is little consolation, Wayne. I know you know that, but you also know that BCBS would not have shifted these drugs up to Tier 5 if the generics were already sufficient for everybody.

I think a closer look at that subset of generic-resistant HIV patients is in order, and if there isn't a plan in place to alleviate some of that huge spike in drug costs, a plan should be negotiated into existence.

Just my two cents, which may only be worth a half-pence.

My team will continue looking into matters like this.

Just wanted to re-assure folks that we'll continue looking at matters like this. As someone who (like folks here on this website) champions consumer protection and good government, the appropriate folks on my team and I will continue our work on this and related matters. My prior post was a deep-dive that I felt folks were owed since time had passed while questions and answers were being traded back and forth. Stay tuned.

Thanks, Wayne

We all appreciate your engagement here, and your concern for insurance consumers.

No. Just no.

NCDOI understands that insured members still had low cost options that were clinically proven just as effective as those moved to the higher cost share Tier 5.

While I appreciate Wayne engaging in a online forum about a complex issue, this is flatly untrue and cannot stand unopposed.

Since it's World AIDS Day, let's take the HIV example. For years you have been on the primary frontline HIV drug in the US (Atripla) and have used it to successfully suppress the virus.

And now BCBS (apparently hand-in-hand with the NCDOI) is telling you to switch to an entirely different class of drugs that do not fight the virus in the same way -- which causes you to form resistance to an entire class of HIV medications (there are 6 major classes of HIV medications).

This will limit your ability to fend of the virus again should it mutate as you age (and it surely will).

Wayne's quote may possibly be true if you'd never been on medication before (also called a treatment naive patient). But everyone impacted by this change is already on a drug that is working.

The same is true of the various cancer drugs. If one is working and has you in remission, why in the world would a health insurance company want to force you (via outrageous and impossible co-pays) off the therapy that is working only to put you through different and therefore longer treatments which inevitably lead to more expense and likely worse health outcomes.

It's horrible for the individual patient, but it doesn't even make mid- or long-term fiscal sense for the health insurance company... unless they openly admit their plan is to bankrupt you and force you onto Medicaid.

In the HIV example, it's also horrible public policy in general because it increases the prevalence of resistant strains of the virus.

Happy World AIDS Day, Blue Cross Blue Shield and NC DOI!