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

ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs

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bmancanfly:
I would check with a different company.  You may not be getting correct/complete info.

I was shopping for Platinum plans in FL today (out of curiosity)and all HIV drugs that I checked were classified at tier 2 with a maximum out of pocket per med  of $50.  Even tier 4 drugs were $150 out of pocket max.

Don't only shop with one company - ever.











emeraldize:
Please contact Bristol-Myers Squibb for a co-pay assistance card. Here's a link for you. If you haven't been taking advantage of this program I blame your provider fir not telling you. In fact, I have decided to take that stance as of this post. If your provider knows whether you are commercially-insured --and they do--then they should be telling a patient to sign up for these programs now offered, I believe, by all ARV makers and some cover meds beyond ARVs. http://www.bms3assist.com/copay/

aaware72:
I just got back from a New Hampshire HIV Planning Group meeting.  Today we heard from Amy Killelea JD with the National Association of State and Territorial AIDS Directors (NASTAD)  Along with the Program Manger if the NH Ryan White Care Program. 

Couple quick things. 

Be sure to check each plan and what formulary that are covered.  They are only required to cover drug from each class. In NH the only plans available are from Anthem Blue Cross Blue Shield in the "Exchange" However Anthem BCBS  do not cover Complera or Stirbild.  What this means is that I will not able to get a subsized plan or premium tax credits.  Look like I will be force to go out side exchange for a policy. 

sfpvguy41:
Today Anthem told me two different things:
1) Since I was told late that my coverage was being cancelled, I have til March 31 to change plans regardless of what happens with extending cancelled plans.  I also read that even though Obama has said they could wait a year, in California there are other contractual issues with the exchanges and insurance commissioner so the insurers can't confirm the extension yet.
2) The second rep today confirmed that the Blue Cross formulary puts HIV drugs in Tier 2, but it is not yet approved by the state insurance commission so it is subject to approval.  Good thing I have some time to wait to change to see if it is finally included.

As of now it looks like I'll have extra time to make a considered change and to keep the copays at $50 with an option for no deductible for $100 more/month, which isn't too bad as there was a deductible before. 

As noted above in this thread, the moral of the story is to try to find out what Tier your meds fall in with your provider before committing to a plan.

mitch777:
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.

m.

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