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

Insurance through employer will not cover specialty drugs - NYC

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So I changed jobs and my new employer's plan (the high PPO plan) does not cover specialty drugs. It's the most expensive plan. All of their plans say that specialty drugs are not covered. Which means that Biktarvy is not covered, nor any other of the HIV meds out there. Despite attempts for prior authorizations and even medical necessity letters, they still denied coverage.

Has anyone else encountered this? Is there anything at all that can be done? I just find it crazy!

Why did you change employer without checking this out first? Join your union, then find another company to work for

Since when? My union plan was a platinum PPO it wouldn't cover specialty drugs at the local pharmacy.  It did cover tier 3 aka specialty drugs through CVS specialty.  I'd check that first.  It was more convienent anyway, 3 month supply mail delivered zero out of pocket cost.  I have not heard of any insurance HMO or PPO denying a drug based on type or class.  Originally mine wouldn't cover bictarvy when it was new.  A year after it was on the market I was fully covered.  Plus your ID can make a continuity of care request to keep you on specificly the same drug.  Don't take no for an answer!  Those are the kind of things in the ACA that didn't get all the media attention.

@harleymc - I was diagnosed one year ago and was never on any prescription medications prior. Therefore it just never occurred to me that a life sustaining treatment may not be covered. Also not a union position.

@MadDog125 - I've been fighting it for a week now. No success yet. Despite all the necessary procedures such as prior auths, medical necessity, etc. They're saying they will not cover any HIV meds...since they are a "specialty medications." Biktarvy is also a tier 2 med.

does your doctor's office deal with the Ryan White program? if not find the Ryan White program (through the state health dpt) for your area. see what assistance or guidance they can give you about keeping access to your ARVs. While you might not be eligible for RW assistance, I have found that RW case managers will always help or figure out how PLWH can get their meds.


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