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Medicare and HIV medications
Dec 23, 2015

My health insurance has covered my Atripla since 2008 but next year I have to drop it because I turn 65. Are there any Medigap or Medicare Advantage programs that will cover me through the doughnut hole since I know I will reach it.

Response from Mr. Vergel

The Affordable Care Act provides for closing the Medicare Part D prescription drug benefit "donut hole" by 2020. Beneficiaries receive a 50% discount on covered brand-name drugs while they are in the "donut hole," with increased savings on prescription drugs while they are in the coverage gap until the gap is fully closed. In addition, ADAP benefits are now considered as contributions toward Medicare Part D's True Out of Pocket spending limit ("TrOOP"), so ADAP clients who have Medicare Part D should be able to benefit.

Over the next five years, Medicare Part D provisions will incrementally expand to eventually fill the donut hole. For people with HIV, starting in 2011, all brand name drugs (including most HIV medications) will be offered at a 50% discount, plus a $250 federal rebate will be paid directly to individuals this year. Currently, ADAP has been covering people stuck in the donut hole through a wrap-around measure, but since ADAP funds cannot be used to fill the hole, this means most people end up getting their medication through ADAP instead. Starting next year, ADAP can help fill the hole, and people will revert back to getting their medications through Medicare, paying just 5% of the drug cost, and freeing up much needed ADAP dollars for others without any drug coverage.

Contact your local ADAP to find out more:

Directory of AIDS Drug Assistance Programs

or call a community clinic in your city and ask to speak to a case manager that may explore options for you:

HIV Non-Profits in the US

Good luck. Please let me know what happens!


HIV+ 15 years, Thoracic Aortic Aneurysm, Prolapsed Heart Valve
Weight Loss

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