Health benefits

Supreme Court hears case of discrimination in health benefits

What would you like to know

  • The case concerns people living with HIV who have been told to obtain specialized drugs from a specialized pharmacy.
  • Patients say this requirement prevents people living with HIV from having the same meaningful access to drug benefits as other patients.
  • AHIP says a decision favoring patients would undermine efforts by health insurers to cut costs and improve the quality of care.

The United States Supreme Court is considering a case that could lead to major changes in how health coverage works in the United States.

The case, CVS Pharmacy v. Doe (file number 20-1374), involves patients who say the prescription benefit rules of a health insurance plan discriminate against registrants with disabilities.

PPACA articles 1557

Section 1557 of the Patient Protection and Affordable Care Act, or PPACA, prohibits discrimination based on disability in federally funded health programs.

The law gives patients the opportunity to pursue claims of discrimination based on disability.

The position of the patients

Patients in the CVS Pharmacy case are using expensive “specialty” drugs to control HIV. Their health plan requires that patients who want drugs to be covered on a network basis to purchase the drugs through a designated specialty pharmacy.

Patients argue that HIV is a debilitating disease and that the requirement to use a specialized pharmacy in the health plan interferes with their ability to have “meaningful access” to HIV treatment, through a restriction that is not imposed on people seeking other types of medication.

Patients argue they can sue if a medicare plan‘s rules have a “disparate impact” on people with disabilities, even if the terms of the plan appear to be neutral, at first glance, toward people with disabilities.

A Chicago District Court judge dismissed the patients’ complaint in 2018.

A three-judge panel of the 9th U.S. Court of Appeals found in 2020 that patients filed a disability discrimination complaint under Section 1557 of the PPACA when they declared their diet health officials denied them “meaningful access” to prescription drug benefits.