Insurance through employer will not cover specialty drugs - NYC

[Ruskidude]

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!

[harleymc]

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

[MadDog125]

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.

[Ruskidude]

@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.

[leatherman]

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.

[MadDog125]

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?

[Matths]

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

[Ruskidude]

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!

[Ruskidude]

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