Anyone on Aetna insurance?

[azprince]

I have insurance through work , it covered me for the last 2 years but it will end soon since I am going to school again, at school they offer me Aetna, but i noticed that it says in the benefits explanation under the pharmacy limits  :
7500 per member for plan year 09/10 through 09/09.
So does it means that I will only be able to buy Atripla twice ?
In this case what should I do? do you think they can increase the limit for me ? is there anyway that I am understanding the pharmacy limit in the wrong way...after all it doesnt make any sense ! note that we must be covered in school because its a full time program so we are automatically enrolled in this insurance but we have the option to chose the comprehensive  or the basic, of course I chose the comprehensive one but now I am reading this 7500 $ limit thing and I am puzzled!
I would appreciate any clarification and guidance

[decayingsinner]

I have Aetna through my employer.  It's alright.  Not fantastic.  My meds are $580 per year and my blood work is a few hundred a year.  I think in total, they cover about $7000 and what's mentioned above is what I pay out of pocket.  Usually, by December my funds are depleted and I may be left with a bill that needs to be paid in full.

[azprince]

Well I am on Atripla, and it costs more than 2000 per one refill, so it means I will run out of limit within two refills, but some friend here PM me and told me that they dont consider Atripla as a Medicine but rather a Medical expanse which means that its under the 1.5 million $ limit...Lets hope that this is the case 

[azprince]

Just contacted Aetna today they refused to cover the Atripla once it will exceed the 7500 per year...simply a fraud since when I signed to the plan they recommended that if I have a Chronic illness I should chose the comprehensive plan that will cover up to 1.5 million per year , now they tell me that unless the medication is given to me inside the Doctors clinic they will not cover an amount exceeding 7500 per year...any ideas on what is the next step I should take

[tednlou2]

I take it you don't qualify for ADAP.  I've been told there are drug programs to help with paying for them (what insurance doesn't cover) or get them for free--think it is with the drug companies directly. 

You said they won't pay over the amount unless you get the meds through your doc office??  Is that right?  Does your doc office/clinic have their own pharmacy?  Mine does.  Would your insurance consider that the doc office giving them to ya or treat it like any pharmacy?  If no pharmacy, I know many offices/clinics have an HIV pharmacist on staff to meet with patients about meds.  I know my HIV pharmacist doesn't fill prescriptions like regular pharmacists.  She is there to educate patients.  Maybe they could help point ya in the right direction.

[1228GUY]

AZPrince, you should also get in contact with Wingspan, it's Arizona's LGBT Comm. Center, they should be able to provide you with some guidance, that is assuming that you are in Arizona (LGBT resources are there for your use regardless of sexual orientation and they are there to assist you in any way they are able to)

http://www.wingspan.org/

[Inchlingblue]

ADAP does have programs for this kind of scenario, i.e. people who are underinsured. You should contact someone who can help in your area. Are you in AZ? In Phoenix for example, it's Body Positive which has now changed their name to Southwest Center for HIV/AIDS.

If you get your insurance through work you also might be able to change to a different policy with more coverage during the open enrollment period.

As tednlou2 mentioned, the drug companies do have co-pay assistance programs, but I think at most they would cover $200./month for some of the meds, not nearly enough to cover what you are being charged.

There are definitely options for you but you need to speak to someone very knowledgeable about these things.

LINK:

http://www.swhiv.org/

[azprince]

Thank you guys for all the information, I am not in AZ anymore, I am in NY , I am still trying to work things with my Aetna insurance, I am seeking legal help now since when I tried to chose the plan we contacted them and told them I do have a chronic illness and I wish to know which plan is better for me and they recommended the Comprehensive student plan, suddenly after visiting the Doctor at the university health center I got this info on my web profile on the insurance navigator indicating that I have a pharmacy limit of 7, 500, as I mentioned calling them the only explanation they came up with is that they means with 1.5 million  a limit for medical treatment including meds given inside the Docs clinic 
I will try to exhaust all my solutions with the insurance company before I try to reach out for other possible options that I might qualify for .
Its sad how the insurance companies can play tricks without being accountable...

But again thanks for the guidance and would appreciate any further recommendations that you think might help force the insurance cover my Meds 

[Inchlingblue]

I think it's a good game plan to try to get them to agree to a different plan since they advised you incorrectly but worse case, NY ADAP should be able to step in and cover the meds.

Is this insurance through school?

[azprince]

Yes it is through school 

[azprince]

I have Aetna through my employer.  It's alright.  Not fantastic.  My meds are $580 per year 

Just curious which Meds cost only 580 per year