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Author Topic: ACA and Tier 5  (Read 2808 times)

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Offline Beamish

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ACA and Tier 5
« on: November 01, 2013, 10:48:35 AM »
Hello Gang, new troller on the boards here.

I'm Greg and was diagnosed in 1991. 

For the last 10+ years I have been on Reyataz+Viramune+Viread. 

Have been fortunate enough most of my adult life to have good employer insurance.  Faced a termination in 2010, and when COBRA ran out, I went on to State High Risk Pool until this year, and have been on ADAP since the spring.

In the past, whether it was employer insurance, indy, COBRA or HRP, my meds have always been covered by co-pay.  In recent years, carriers have forced me over to "specialty pharmacies" and the co-pays have gone up, but they were still co-pays.

Now after reviewing the coupla-dozen plans that healthcare-dot-gov presented me with, EVERY ONE of those plans, from bronze to platinum, has all TIER 5 meds on 30% COINSURANCE.

So my regimen which I am used to paying $100+/- in copays, will now be more than $1,000 per month.

I'll say on the upfront, I know I am fortunate; a lot better off than a lot of our compatriots here.  I've survived 20+ years, usually with a solid HC support base.  Only in recent years have I been financially distressed. 

But here are my questions at this moment:

  • Has Tier 5 in the past been excluded from co-pays?
  • Saw somewhere here that ADAP may not drop if you have some insurance. True? My clinic say it will drop.
  • Are there other features of RW besides ADAP that I should look into?  I hear some of you saying "I receive both RW and ADAP..." 

Greg Out..
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CD4: 1780  VL: <5
« Last Edit: November 01, 2013, 11:05:22 AM by Beamish »

Offline JR Gabbard

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Re: ACA and Tier 5
« Reply #1 on: November 01, 2013, 11:58:39 AM »
Hi Greg,
Welcome in from the dark!
Generally speaking, ADAP (AIDS Drugs Assistance Program) covers med co-pays.  They sometimes pay the premiums on COBRA policies and Medicare, depending on your state.  The program is means-tested, and the eligibility varies by state, but you can usually qualify with a relatively high (for disabled people) income.  ADAP considers itself the payer of last resort, so you need some other type of insurance to compliment it.  It is a state-run program, though, so whether ADAP would drop you depends on the rules in your state.
Ryan White is an umbrella law (it covers a lot) that provides, among other things, funding for medical services for people with HIV.  It is heavily means-tested, so only people with very low income usually qualify.  When someone says they are getting RW, it means they get their care from a RW funded clinic, and ADAP likely covers their meds.
If you've been out of work since 2010, it might be time to consider applying for SSDI.  When you are over 50 (just a guess, apologies if it doesn't apply yet) you would be eligible for a new set of assumptions regarding your employability.  In practical terms that means you might qualify even if you've had only relatively minor health problems.  I mention this because SSDI means eligibility for Medicare (2 1/2 years later, however) which would solve the insurance problems you've listed.  If you want to pursue that route, speak to a local attorney.  Not a non-attorney rep for this one, though.  It might need to go to a hearing.
Also, have you applied for all the subsidies on the exchange that you night be eligible for?  That could take out some of the sting.
Best of luck!
It goes like this
The fourth, the fifth,
The minor fall, the major lift,
The baffled king composing Hallelujah!

L. Cohen

Offline Beamish

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Re: ACA and Tier 5
« Reply #2 on: November 01, 2013, 03:53:54 PM »
Thank you JR.  That gives great clarity on RW/ADAP, thanks the SSDI advice is helpful. and yes, i'm 50½.   :P 

What I am really most curious about is whether Tier 5 Meds have a history of being excluded from copay, or whether it is a new adjustment from carriers to compensate from the other losses ACA is creating for them. 

Yes, I have included the tax subsidies available.  In general, the premiums are not bad, but the deductibles are averaging at what was once a high deductible. 
« Last Edit: November 01, 2013, 03:56:16 PM by Beamish »

Offline JR Gabbard

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Re: ACA and Tier 5
« Reply #3 on: November 02, 2013, 11:39:15 AM »
Private insurance companies have free reign to set their own prices for drugs, and to create any tier structure they want.  Specialty drugs (tier 5 or 4, depending on the company) almost always require special handling and sometimes have hefty co-pays, which is why it pays to shop around.
I don't think what you're running into is related to the ACA in any real way, though.  Private insurers now have to pay a certain percentage of their annual revenues out in benefits every year, or return that money to the insureds, as opposed to passing it along as a dividend to the stock holders.  So there's no sound business reason to jack up their prices.  In my humble opinion!  :)
Is it political?  I can't say.
It goes like this
The fourth, the fifth,
The minor fall, the major lift,
The baffled king composing Hallelujah!

L. Cohen

Offline OneTampa

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Re: ACA and Tier 5
« Reply #4 on: November 03, 2013, 03:09:13 PM »
Welcome Greg and thanks for your inquiry and JR for your replies. 

This information is helpful to me as I have started a new job but currently carry COBRA and am pleased with the benefits.  I am working to transition to the company sponsored insurance. I see the small company plan requires that the employee pays part of the monthly premium (pre-tax at about $120), co-pays, and mail order 90 day supply pharmacy.  I also saw a pre-existing condition section that notes delayed insurance eligibility for a period in the benefits summary I need clarified.

Bottom line, it seems that I will pay a bit more money out of pocket than I have paid in the past thus reducing my take home pay. I also need to understand the company insurance coverage relevance and adherence to the ACA rules along with any other possible options. Will get more details this coming week after meeting with HR. 
« Last Edit: November 03, 2013, 03:12:58 PM by OneTampa »
"He is my oldest child. The shy and retiring one over there with the Haitian headdress serving pescaíto frito."


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