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Medicare Part D & Ryan White HIV/AIDS Program

 
PDF Medicare Part D & Ryan White HIV/AIDS Program
(PDF – 69 KB)

The Basics

The Medicare prescription drug benefit.
People with HIV/AIDS can benefit substantially from Medicare’s new drug coverage (Part D). Medicare prescription drug plans provide insurance coverage for prescription drugs. These plans are offered by insurance companies and other private companies. Plans cover both generic and brand-name prescription drugs.

Part D plans are offered in two ways: as stand-alone plans and as prescription drug coverage added to Medicare Advantage Health Plans (like HMOs and PPOs).
Eligible individuals can choose the plan that meets their needs. Drug plans may vary by state as they are packaged and offered to regions across the nation.

Enrolling in a Part D Medicare plan.
Medicare-eligible individuals who do not have prescription drug coverage that is at least as good as a Medicare prescription drug plan (called “creditable coverage”) should enroll in a Medicare prescription drug plan. There may be a penalty for failure to join by the deadline, as follows:

  • Newly Medicare Eligible. You have a 7-month window for enrolling without a penalty: 3 months prior to the month your eligibility begins and 4 months after the start of your Medicare eligibility.
  • Lose Creditable Coverage: If you lose creditable coverage, you will face a penalty if you fail to join within 63 days of losing that creditable coverage. If not enrolling within this time frame, the next opportunity to join is November 15 - December 31 of each year. This penalty is added to the monthly premium and is 1% more for every month of delayed enrollment. This penalty will be in force for as long as the individual has Medicare prescription drug coverage.
  • With Creditable Coverage: For those individuals with creditable coverage who decide to join Part D at a later time, there is no penalty for not joining. For those who lose creditable coverage, there is no penalty for late enrollment if a Part D plan is joined within a 63 day period.

Since ADAP typically covers only HIV-related medications, it is not creditable coverage. Those individuals whose only coverage is ADAP and who delay enrollment in Medicare Part D will have to pay this penalty when joining Part D late. One exception is when ADAP offers comprehensive drug coverage under, for example, a health insurance continuity arrangement.

How eligible persons get on a Medicare prescription drug plan.
Individuals should select a prescription drug plan that meets their medication, financial, and other needs. The Medicare Prescription Drug Plan Finder can help individuals select the right plan. It provides detailed cost sharing and formulary information for prescription drug plans and Medicare Advantage prescription drug plans. CMS also operates the 1-800-MEDICARE help line.

How dually eligible individuals enroll in Part D.
Dually eligible individuals are auto-enrolled in a plan. They can stick with the assigned plan or choose another one. In picking a drug plan, dual eligibles should use the same considerations and resources as are used by all Medicare-eligible individuals.

When you can change to another Part D plan.
There are various conditions under which a person can change to a new plan, as follows:

  • Everyone on Part D can switch to a new plan during the annual open enrollment period, November 15 – December 31 of each year.
  • Those eligible for any type of low income subsidy can make changes in plans at any time.
  • A person who moves to a new geographic location that does not offer the same plan can switch to a different plan.
  • A Medicare beneficiary who believes he was misled into enrolling into a Private Fee-for-Service plan has the opportunity to change plans under a Special Enrollment Period (call 1-800-MEDICARE and describe the misleading information and a customer service representative can assist with this issue).

Prescription Drug Plans and Drugs Covered

Drugs that are included—or not included—in Part D prescription drug plans.
Part D covers all FDA-approved drugs except the following: drugs covered under Medicare Parts A and B and seven categories of what are called excluded drugs. Examples of excluded drugs most relevant to HIV-related care include those for weight loss or weight gain (although drugs used for AIDS-related wasting or cachexia are considered Part D drugs), over the counter drugs, vitamins and minerals, and benzodiazepines. For dual eligibles, these excluded drugs may still be available to them under Medicaid.

Part D prescription drug plans have flexibility in determining what drugs to cover and how to cover them, such as cost-sharing requirements. Plans can decide which drugs to include by using a formulary (a list of covered drugs) or by covering all FDA-approved prescription drugs.

If using a formulary, the plan is required to cover both generic and brand-name prescription drugs and include at least two drugs in each class. In order to protect against discrimination, CMS requires access to all or substantially all drugs in six drug classes in the formulary. One of these classes of drugs is antiretrovirals. All Medicare prescription drug plans will be required to cover all antiretroviral drugs, including single chemical entities as well as combination products.

When it comes to adding new FDA-approved drugs to plan formularies, Part D plans have Pharmacy and Therapeutic (P&T) committees that are responsible for making this decision. They are to make reasonable efforts to review new chemical entities (including new antiretrovirals) within 90 days of their release on the market and make decisions about whether to add them to a plan’s formulary within 180 days. A clinical justification is to be provided if this timeframe is not met. Part D plans must add drugs recommended by their P&T Committee.

How drug plans differ, such as drugs that are covered and their costs.
Yes. Drugs may be offered by plans at different co-pay levels and plans may supplement the benefit for those patients who are willing/able to pay a higher monthly premium. Plans may have different policies with respect to commonly prescribed drugs—and drugs for which there is evidence of clinical equivalency. HIV therapy may necessitate access to specific drugs within a class. Thus, formulary access to (and cost-sharing requirements for) non-HIV medications may be particularly important to consider when selecting a prescription drug plan.

How to file an appeal if the drug is medically necessary but not included in a plan’s formulary.Prescription drug plans under Part D have a choice on what drugs to cover and how they will cover them, such as cost sharing and other tools to manage drug utilization in keeping the cost of the drug benefit affordable. Following are some specifics about drug coverage under plans:

  • If a specific drug is covered but the plan changes its formulary during the year, the plan must keep patients on that drug for the remainder of the plan year.
  • If a specific drug is not covered by the drug plan, or is included but at a high cost tier, the first step is for the patient and clinician to discuss which drugs are best for their treatment. If the physician determines that the drug(s) is medically necessary, a request for an exception to the formulary or cost sharing can be filed with the plan. Medicare drug plans are required to make the initial decision on an exceptions request within 72 hours or within 24 hours for urgent situations. Requests for exceptions that are declined by drug plans twice may be appealed to a process external to the plan. Clinicians and other staff may act on behalf of patients in requesting exceptions and appeals. Information on the exceptions and appeals process, including a form for clinicians to use (as a patient’s representative) to request an exception.