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Huge Increase in Co-Pay
Apr 2, 2009

I have been HIV positive since summer, 1993 and was on various drug treatments over the next few years with good results. In 2004 I went off meds completely with little change to my viral load and CD4 counts until last year. I began taking Atripla in February, 2008 when my CD4 cell count dropped to 202 and my viral load began to increase. My viral load is now undetectable and my last CD4 count was near 400. The Atripla medication has been available to me through my health insurance by mail order. I've been getting a 3 months supply at a co-pay of just $70 for the last year. A change to our health insurance this year has reclassified, not only the Atripla medication, but ALL medications that treat HIV to a Tier 4. All Tier 4 drugs are now only available month to month at a co-pay of 35% of the cost of the drug up to a maximum of $500. Therefore, my co-pay has gone from $70 for a 3-months supply to $435 per month. I cannot afford medication at this price. In researching my options, I have found that, based on their new policy, there are NO options that are more affordable and I must now discontinue my treatment because of the cost. I spoke with our companys Benefits Manager about my situation. She told me that the Tier 4 structure was intended to control costs by moving expensive name brand cocktails and injectables to this tier so that other, less expensive, treatments would be considered. I have NO less expensive alternatives. I have verified this through my doctor. The attached paperwork clearly identifies my condition as a condition now requiring medications to be purchased through the Specialty Pharmacy Program which is where the new month-to-month and 35% co-pay costs are the policy. Can an insurance company do reclassify drugs to require a higher co-pay based on the condition they treat and provide no alternatives? I've filed a complaint with the state Insurance Board, but haven't head anything yet. Additionally I've spent the last month trying to find co-pay assistance but I make too much money to qualify - though not nearly enough money to afford $435 per month, not too mention an increase in my premiums this year, and the usual cost of lab work and doctors visit co-pays. Can you offer any guidance?

Response from Ms. Franzoi

I am sorry that I cannot offer you much guidance. This type of plan design is legal. Many plans do this in an effort to control cost. If you have another plan option such as an HMO, you should check at open enrollment which plan would offer the most comprehensive coverage for you.

Have you tried the Specialty Pharmacy? Is there an out-of-pocket maximum under this program?

insurance denying claims
Received letter from Ingenix Subrogation

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