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Drug Coverage on Prescription Plan
Oct 21, 2005

I will be leaving my current employer where I have group health coverage and am currently using the prescription plan for Sustiva and Truvada. I am looking to change jobs and go with a startup firm that is in the process of establishing their healthcare plan. They do no know yet who they will be using, but will have a plan in place within 90 days. For the time being, I will use COBRA, and any pre-existing clause that may exist in the new plan won't be an issue because of HIPAA portability and the fact that I have over 12 months of coverage at my current employer. My question is: Are most HIV drugs (specifically Sustiva and Truvada) covered under most major medical plans with prescription plans? I'm concerned about a healthplan being chosen where maybe those meds wouldn't be covered. I'm OK with a co-pay, but I want to avoid non-coverage. It would like be a major plan like Blue Cross, Cigna, Aetna, United, etc. Are you aware of any major plans that do not cover these drugs?

Response from Ms. Franzoi

If the new company goes with one of the major carriers, you shouldn't have a problem with these drugs. Many prescription drug plans have formularies, i.e., drugs that are in their Rx formulary and those that are not. With an open formulary, the plan will pay a higher portion of the cost of a formulary drug than a non-formulary drug. Some plans have a closed formulary which means that non-formulary drugs are not covered. This would be in the case where there are multiple drugs in the same drug category and the plan only covers one of them. With many AIDS medications, there often aren't mutiple drugs within the drug category so the "single" drug is considered to be a formulary Rx.



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