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Author Topic: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs  (Read 1797 times)

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Offline sfpvguy41

  • Member
  • Posts: 115
ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« 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?

Labs: (undetectable since 2005)
12/13: 634 cdr, 37.3%, 758 cd8, total chol 183, triglycerides 131
8/13: changed to Edurant from Reyataz
12/12: 828 cd4, 34.5%, 1078 cd8, total chol 192, tri 196
12/11: 787 cd4, 37%, 979 cd8.
9/11: 758 cd4, 38%, 944 cd8, und.
8/11 dropped norvir, incr reyataz to 400 mg
6/11: 621 CD4 CD4% 41, CD8 680! Undetectable. Creatinine and eGFR are ok now.
Switched from Truvada to Epzicom in late April 2011
AGT/AST and creatinine back to normal mid-April.
Cut Norvir from regimen.
Switched back to Reyataz/Norvir late Feb 2011
2/11: CD4 664 34%, CD8 963, diagnosed with osteoporosis, high AGT/AST and creatinine.
12/10: CD4: 676 CD4%: 34 CD8: 1012
Switched from Reyataz/norvir to Isentress 10/10
8/10: CD4: 731 CD4%: 40 CD8: 866
Diagnosed Sept. 2002 started meds May 2005.

Offline sfpvguy41

  • Member
  • Posts: 115
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #1 on: November 14, 2013, 07:42:27 PM »
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?
Labs: (undetectable since 2005)
12/13: 634 cdr, 37.3%, 758 cd8, total chol 183, triglycerides 131
8/13: changed to Edurant from Reyataz
12/12: 828 cd4, 34.5%, 1078 cd8, total chol 192, tri 196
12/11: 787 cd4, 37%, 979 cd8.
9/11: 758 cd4, 38%, 944 cd8, und.
8/11 dropped norvir, incr reyataz to 400 mg
6/11: 621 CD4 CD4% 41, CD8 680! Undetectable. Creatinine and eGFR are ok now.
Switched from Truvada to Epzicom in late April 2011
AGT/AST and creatinine back to normal mid-April.
Cut Norvir from regimen.
Switched back to Reyataz/Norvir late Feb 2011
2/11: CD4 664 34%, CD8 963, diagnosed with osteoporosis, high AGT/AST and creatinine.
12/10: CD4: 676 CD4%: 34 CD8: 1012
Switched from Reyataz/norvir to Isentress 10/10
8/10: CD4: 731 CD4%: 40 CD8: 866
Diagnosed Sept. 2002 started meds May 2005.

Offline buginme2

  • Member
  • Posts: 2,944
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #2 on: November 14, 2013, 07:49:20 PM »
 Obama  just made a speech today saying they would allow people to keep their current plans for one more year. 


Offline mitch777

  • Member
  • Posts: 3,539
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #3 on: November 14, 2013, 07:59:46 PM »
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.
31 years hiv+ (oct. 2013) with a curtsy.

Offline sfpvguy41

  • Member
  • Posts: 115
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #4 on: November 14, 2013, 08:10:17 PM »
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". 
Labs: (undetectable since 2005)
12/13: 634 cdr, 37.3%, 758 cd8, total chol 183, triglycerides 131
8/13: changed to Edurant from Reyataz
12/12: 828 cd4, 34.5%, 1078 cd8, total chol 192, tri 196
12/11: 787 cd4, 37%, 979 cd8.
9/11: 758 cd4, 38%, 944 cd8, und.
8/11 dropped norvir, incr reyataz to 400 mg
6/11: 621 CD4 CD4% 41, CD8 680! Undetectable. Creatinine and eGFR are ok now.
Switched from Truvada to Epzicom in late April 2011
AGT/AST and creatinine back to normal mid-April.
Cut Norvir from regimen.
Switched back to Reyataz/Norvir late Feb 2011
2/11: CD4 664 34%, CD8 963, diagnosed with osteoporosis, high AGT/AST and creatinine.
12/10: CD4: 676 CD4%: 34 CD8: 1012
Switched from Reyataz/norvir to Isentress 10/10
8/10: CD4: 731 CD4%: 40 CD8: 866
Diagnosed Sept. 2002 started meds May 2005.

Offline bmancanfly

  • Member
  • Posts: 580
  • Medicare For All !
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #5 on: November 14, 2013, 09:44:55 PM »
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.











"The trouble with the world is that the stupid are cocksure and the intelligent are full of doubt."

 Bertrand Russell

Offline emeraldize

  • Member
  • Posts: 3,348
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #6 on: November 15, 2013, 05:25:07 AM »
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/
« Last Edit: November 15, 2013, 05:35:03 AM by emeraldize »

Offline aaware72

  • Member
  • Posts: 226
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #7 on: November 15, 2013, 01:32:40 PM »
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. 
"Yes, knowledge is power. Self-knowledge brings mastery of one's body."

Offline sfpvguy41

  • Member
  • Posts: 115
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #8 on: November 15, 2013, 04:25:51 PM »
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.
Labs: (undetectable since 2005)
12/13: 634 cdr, 37.3%, 758 cd8, total chol 183, triglycerides 131
8/13: changed to Edurant from Reyataz
12/12: 828 cd4, 34.5%, 1078 cd8, total chol 192, tri 196
12/11: 787 cd4, 37%, 979 cd8.
9/11: 758 cd4, 38%, 944 cd8, und.
8/11 dropped norvir, incr reyataz to 400 mg
6/11: 621 CD4 CD4% 41, CD8 680! Undetectable. Creatinine and eGFR are ok now.
Switched from Truvada to Epzicom in late April 2011
AGT/AST and creatinine back to normal mid-April.
Cut Norvir from regimen.
Switched back to Reyataz/Norvir late Feb 2011
2/11: CD4 664 34%, CD8 963, diagnosed with osteoporosis, high AGT/AST and creatinine.
12/10: CD4: 676 CD4%: 34 CD8: 1012
Switched from Reyataz/norvir to Isentress 10/10
8/10: CD4: 731 CD4%: 40 CD8: 866
Diagnosed Sept. 2002 started meds May 2005.

Offline mitch777

  • Member
  • Posts: 3,539
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #9 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.

m.
31 years hiv+ (oct. 2013) with a curtsy.

Offline aaware72

  • Member
  • Posts: 226
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #10 on: November 16, 2013, 10:15:34 PM »
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.

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. 
"Yes, knowledge is power. Self-knowledge brings mastery of one's body."

Offline OCPozGuy

  • Member
  • Posts: 4
Re: ACA Plans Classify Antiretrovirals as Specialty "Tier 4" Drugs
« Reply #11 on: November 20, 2013, 12:57:14 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?

sfpvguy41,

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:

https://www.blueshieldca.com/bsca/documents/pharmacy/Standard_Formulary.pdf

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

https://www.blueshieldca.com/bsca/sbc-assets/public/ifp/Ultimate_PPO_SBC_1-14.pdf

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

https://www.blueshieldca.com/bsca/sbc-assets/public/ifp/Preferred_PPO_SBC_1-14.pdf

Hope this information is helpful.

 


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