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Basics of HIV treatment coverange by insurance companies
Feb 7, 2014

Hello! Can you please answer a few of my questions so I could understand certain basics of what is going on with HIV treatment coverage in the U.S. by insurance companies? I spent much time looking for an answer online but I want to make sure I understand everything correctly.

My situation is the following: I am a citizen of another country and currently taking AZTs that work really well for me and I want to stick to them (efavirenz + lamivudine + zidovudine). I may be going to legally work in the U.S. permanently because I have a job offer. I know that my employer will provide me with a choice of insurance plans when I am hired. Now, the questions are: 1. How can I find out which of the provided plans covers the exact treatment I need? (without disclosing too much of the personal information to the employer) 2. Is it possible that none of the provided plans will cover it? 3. Is it possible to have both employer's coverage (not covering my treatment) and also individually sign up for some special insurance plan that will help me get my medications? 4. Where can I find at least approximate cost values of my kind of treatment for people with and without insurance coverage? 5. What is the deal with ADAP and Pre-Existing Condition Plan, in short? Will they help me in any way?

Thank you so much for your help Anton

Response from Mr. Chambers

I'll certainly try to answer your questions. 1. Virtually all employer provided group health plans will cover you treatment as they would any other condition. However, the only way to know for sure that your meds are covered by your insurance plan is to see each plan's formulary of what drugs they cover. The difficulty there is the formulary is not normally given out at enrollment. The more you pressure your employer to get the formularys, the greater the chance the employer will wonder why you're so concerned. You can try to see if the formularies are on line, but each insurance company usually has several formularies they use with various plans.

However, I will say that most of the HIV medications are covered by virtually all plans.

2. No, it is not possible that none of your employee choices will cover your specific medications.

3. At the moment, there are not any insurancd plans to supplement an employer provided group health plan. With the advent of Obamacare, some carriers are looking to offer supplemental plans to those, but they probably won't be on the market for at least a year, if ever.

4. There are more cost levels for medical care than there are airline prices. It depends on whether the charge is for someone with insurance or someone without. Even if you find a source that gives the "retail" cost of a medication or treatment, it is doubtful that is the amount that will be charged to you.

5. ADAP (AIDS Drug Assistance Program) is a federally funded plan administered by each state. Most provide eligibility to anyone earning less than $50,000 per year, and they will pay what insurance does not pay for the medications that are on the ADAP formulary. Each state is different. Some states have very limited formularies; others are extremely broad. If you do a browser search for ADAP plus a state you will get information on that state's program.

Keep in mind that if you qualify for ADAP and your medications are on the ADAP formulary in the state where you'll be going then it really doesn't matter if your health insurance covers your medications or not, although it means ADAP will be absorbing the entire cost of your medication.

The Pre-Existing Conditions Insurance Plan (PCIP) became unnecessary January 1, 2014 when federal law required all health insurance plans to accept any applicant regardless of their health history or medical condition. For information on those individual plans that are now available go to www.healthcare.gov.

Overall, I don't think you will have a problem with getting your treatment covered by health insurance. If you are coming from a country with a national health plan and you were covered, your employer plan will pick up any pre-existing conditions as well.

Chances are your employer provided plan will give you the coverage you need. Also, your employer will probably be paying the majority of the cost of the plan, and the amount he/she pays for you coverage is not considered taxable income to you.

Welcome, Jacques



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