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Medicare coverage of Atripla
Apr 16, 2014

I have been HIV+ since 2010. In three years I will reach 65 and must enroll in Medicare 6 months prior. I have not yet started any research on Medicare and its prescriptions coverage but am aware of the donut clause and the need for supplemental insurance policies. But does Medicare cover Atripla to begin with?

Response from Mr. Chambers

As of now, Medicare requires that all Medicare Prescription Drug Plans cover all the major HIV medications so Atripla should be covered by all.

There was a proposal to eliminate the rule that they cover all, but that was quickly dropped due to a large outcry from patients, so there are no changes.

As your eligibility for Medicare gets closer, there are some things you can do to be prepared for it when it comes.

First, you should enroll in Medicare about three months before the month in which you turn 65 so that all the paperwork will be done and processed.

About the same time, you should go to www.medicare.gov and click on the link to Find A Drug and Health Plan. There you will be able to enter all your medications and you will get a listing of the available drug plans in order or "lowest-out-of-pocket." Note that it does not take into consideration what ADAP (AIDS Drug Assistance Program) might pay so if you are on ADAP, you need to consider that as well.

You know that you will have a choice of plans. You may enroll in a Medicare Advantage Plan. These are mostly Health Maintenance Organizations (HMOs) and those plans often include a drug program in the plan.

The alternative would be to stay with original fee-for-service Parts A & B of Medicare. To that you can add a stand-alone drug plan, called PDPs.

With original Medicare, you may also want to consider a Medicare Supplement or Medigap plan. They are available through private insurers and will cover deductibles and copays that Medicare does not cover depending on which Medigap plan you purchase. Medigap Plan F is the broadest plan (and, of course, the most expensive).

You can find information about Medigap and Medicare Advantage Plans in your area at www.medicare.gov also.

If your income is low, you may also want to apply for Extra Help with the drug plan coverage. You can apply for Extra Help on line at www.ssa.gov.

Good luck, Jacques



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