Meds, Mind, Body & Benefits > Insurance, Benefits Programs & HIV

ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs

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sfpvguy41:
I just spent a good part of my day figuring out my health care plan options as a recipient of an Anthem Blue Cross CA letter saying they were cancelling my plan.  I'm a bleeding heart liberal so I'm not blaming "Obamacare" but as things stand this is really bleak for me.  I'm giving the summary here and would like to know if anyone has any experience or solutions here.

My current plan costs under $500/month and has a $500 deductible for meds, then a co-pay of $50 per 30 day supply.  So for Edurant and Epzicom I pay $500 in January then $100/month.  Last year Anthem re-categorized my meds as "specialty" and made me get them through Curascript mail order.  But I was ok with that, now I know why.

Under the new ACA plans, there are 4 tiers of drugs.  According to the Anthem rep today, ALL ANTIRETROVIRALS AND PROTEASE INHIBITORS ARE TIER 4.  Under the Bronze-Silver-Gold ACA structure, I would have to pay 30%-20%-10% on buying these meds up to the out of pocket limit.  The best gold plan they show is only an HMO (not my current doc) and would cost 10% of $6700/month for these two prescriptions, or $670/month on top of a $700 premium.  This plan has a $4000 out of pocket limit so I would pay $670/month for 6 months, then just the premium price of $700. 

This increases my healthcare from about $4800 premiums plus $2150 for drugs annually to $8400 in premiums plus $4000 for drugs, an increase of over $5000!  I only used about $500 of my deductible this year (mainly on deductible for my labs) so I can argue I'd only pay $3500 on drugs.

I am now one of those people hoping Obama, or Congress or whoever it takes changes the law to allow me to keep my old plan.

Anyone have any advice or other ideas?

sfpvguy41:
I found this list of drugs online http://www.anthem.com/ca/CAExchangedruglist4.pdf which shows Edurant and Epzicom, along with Atripla and others in Tier 2 ($50 copay).  Now the nice man from the pharmacy area of Anthem told me that it was "confusing" and "things were changing a lot with drugs lately" but he confirmed that while they were listed by name in Tier 2, all antiretrovirals were in Tier 4.  I asked him to confirm that those two drugs by name were Tier 4 with a supervisor and he confirmed that they were and admitted it was "confusing" that they were in the list as Tier 2.

Has anyone got any other info on this for Anthem CA or other plans?

buginme2:
 Obama  just made a speech today saying they would allow people to keep their current plans for one more year. 

mitch777:
Thanks for the post. How can they list a drug as one tier when it isn't? Ugh! If people are basing their decision on which plan to purchase based on this.... ugh!

I spent most of the day online too. Not with Anthem (my current insurer) but the health exchange. Yes, another ugh!

They actually were helpful but is still was a struggle.

Sfpv... Are you eligible for any subsidies? I know I am and the savings will be huge.

sfpvguy41:
i just found another Anthem list showing all HIV meds on Tier 4, but it is dated 11/11, and the one with them on Tier 2 is dated 1/14.  So I hope the rep was wrong.  And I wonder if all insurers are doing this or just Anthem.

Obama proposed extending plans for a year, I think, which means these problems can still kick in in a year.

The 11/11 Anthem list: https://www.anthem.com/ca/health-insurance/nsecurepdf/pharmacy_ABC_Tier_4%20_DL_Local moved all HIV meds to Tier 4.

This is really confusing. 

Another article from the LA Times in July '12 talked about insurers moving HIV drugs to Tier 4 in various employer plans to save employers money, and how NY had outlawed that and CA was discussing it.  And the CA list from 1/14 says "subject to state approval". 

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