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

ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs

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--- Quote from: mitch777 on November 16, 2013, 10:58:06 AM ---I noticed in some of the plans that tier 4 drugs are not covered "unless medically necessary". A doctor would need to state the reason in a letter. Even if that would to occur, I'm not sure if the cost would be applied to the deductible or the max out of pocket.

Not sure if this is helpful in your case but I found a plan with a $3000. out of pocket max which no doubt I will hit every year. Without the premium tax credit my plan would still be quite expensive at around $7,800. per year just for the premium itself.

Previously I was forced to pay a crazy high premium of $12,000. per year and still forked out thousands in out of pocket costs so these plans are saving me money. Still, it disappoints me that these plans are so expensive without the tax credit and that the clarity of coverage is so elusive.


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I'm waiting on a e-mail with some information to pass along, however it is my understanding when it come to any copay on any plan everything other than your premium gets apply to your max out of pocket. 


--- Quote from: sfpvguy41 on November 14, 2013, 06:59:29 PM ---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?

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First I'm new to posting here but not new to following the forums for the past 5 year.

I live in OC and have been investigating switching to an Exchange plan here in CA being that both my coverage will be better AND my premium will be lower (Platinum at $527 a month - 49yo).  Not sure of your age and yearly income amounts but I'm sure you have checked if you qualify for any of the subsidies, I happen to not but that's ok.

I don't know if the plans offered in SF, I'm assuming you are in SF by your forum name but down here in OC Blue Shield offers a PPO at all levels and I have found that their formulary coverage for right now is far superior than Anthem's and I've had Anthem in the past and RAN away from them when they were forcing people to go mail order before the state stopped them.

If Blue Shield is offered and is a PPO is your doctor in their PPO Network?  If they are you might want to look at the Blue Shield plans as their formulary includes most ARV's in tier 2 or Brand Name covered, at least in their Gold and Platinum levels.  And, if it is not on the formulary it is considered a "Non-Preferred Brand Drug", which still has a fairly reasonable $ copay per 30-day supply.

Here is the link to the formulary:

Here is a link to the Ultimate (Platinum) PPO Summary of Benefits:

here is a link to the Preferred (Gold) PPO Summary of Benefits:

Hope this information is helpful.


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