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

Insurance through employer will not cover specialty drugs - NYC

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Tier 2 means even less of an excuse.  Who is the carrier?  In all seriousness under the ACA you can't be denied coverage on a drug that is not optional.  He's right to point out the ryan white foundation.  Still there shouldn't be a need.  Even bronze plans would cover AVRs, just with a higher deductible.  I deal with medical insurance alot on my mother's behalf.  If you have a script from an ID they really have no recourse.  It may just be a question of who you need to talk to.  Plus I hate to ask but is it a small company?  Bigger companies with large group plans usually have a case worker assigned to a particular company as a group client.  If your company has one you may need to go over their head.  You have a benefit provided in good faith by your company.  This isn't an elective surgery, I can't imagine what argument they would even try to make.  If they argue the newest combo drug what about an older coctail?

Hi Ruskidude, sorry that you go through such aggravations. However, as others have pointed out: it is the law and a patient right to get HIV treatment based on accepted medical practices which includes ARVs. No insurance plan can deny accepting you because of a pre-existing condition.

Biktarvy is a specialty drug, tier 5 (and not tier 2). Needs authorization by your treating physician and will be given to you only 30 tablets at a time.

My suggestion is to go back to your doctor, have him justify (usually online or via phone) his decision to treat you with the medicine he considers most appropriate for you, and there shouldn’t be an issue. It’s the doctor who calls the shots in this situation, and not you or the insurance company. They have no choice other than following his/her orders as long as they are based on the accepted guidelines. Best Matt

So my insurer is Blue Cross Blue Shield. The tier really depends on the insurer. Yes, generally it is a tier 3 or tier 5 specialty medications, however the tiers differ between insurance carriers and their formularies. For example, for United Health Care as well as CVS Caremark formularies, it is a tier 2. With my insurance currently, it is a tier 3. Tier 3 are not covered at all.

My income far exceeds the maximum for financial assistance and other programs such as Ryan White and Gilead's Advancing Access.

My doctor's office tried prior authorizations, medical necessity paperwork, etc.

And yes, this is certainly what the ACA does not tell you! I even tried to call the NYS health marketplace to see if any of the plans cover the medication. I spoke to a few people and didn't really get anywhere. They directed me to Medicaid...for reasons unknown. I could only wish I was eligible for Medicaid! When looking at the marketplace, all the plans say "not applicable" for specialty medications. So even if I was to potentially get a second plan...or drop my employer's plan for one of those, I'm still uncertain if they would cover.

Feeling screwed at the moment!

@leatherman - I'll try to reach out to RW today if they can provide any guidance.


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