Will my Medicare Part D plan cover my HIV medications, and can the plan drop them from its formulary?

Question

Samantha Jellison · Accepted Answer

Yes, Medicare Part D, as well as Medicare Advantage are legally required to include all or substantially all of the antiretrovirals, since they are a protected drug class. Although, it is important to know that coverage depends on whether the drug is used for treatment or prevention. 

Part D medications: these are medications covered on your plan's formulary. They are medications that you pick up at the pharmacy or have shipped to you at home. Commonly, these are tablets or capsules which treat HIV.

Part B medications: these are medications received in a medical office or facility and administered by a healthcare professional. These are billed differently than medications covered by Part D. Rather than a co-pay, you will be responsible for the 20% coinsurance that Medicare does not pay. If you have Traditional Medicare with a Standalone Prescription Drug Plan, you will pay 20% of the Medicare contracted rate. If you have a Medicare Advantage plan, you will pay 20% as well. If you have a Medicare supplement plan, and depending on what plan you have, such as a Plan G, a Plan F or a Plan N, your insurance company will cover the 20%. If you have a High Deductible Plan, such as HDP G or F, you will have 20% cost share until you reach your deductible. Typically preventative medications, such as PrEP, would be a Part B medication.

As for whether the plan will drop a drug from its formulary, that is something you will need to review on a yearly basis. Formularies are locked in for the year. During Annual Enrollment Period you need to review your drug plan or Medicare Advantage plan in order to ensure your prescriptions are covered on your plan for the following year. Historically, formularies do not drop coverage for a drug during the plan year.

Bhavin Parikh · Answer

Yes, your Medicare Part D plan (or Medicare Advantage plan with prescription coverage) must cover your HIV medications.
Plans review and update their formularies annually. While they must still abide by the "substantially all" rule for HIV drugs, they may shift a drug to a different cost tier (changing your copay/coinsurance) or swap equivalent treatments for the upcoming year.
Your plan is required to send you an Annual Notice of Change (ANOC) every fall detailing any tier shifts or cost changes taking effect on January 1.

Maricela Cisneros · Answer

Yes, generally. Medicare Part D plans must cover all or nearly all HIV treatment medications because they have special coverage protections.

Your plan cannot simply drop your medication to save money. Limited changes are allowed, such as when a drug becomes unsafe, leaves the market, or is replaced with a generic under Medicare’s rules.

Always check your specific medications and costs before choosing a plan. If you receive a notice about a coverage change, contact your plan and HIV care provider right away to help keep your treatment on track.

Justin Lester · Answer

Yes! Medicare Part D plans are required to cover most HIV medications because they belong to a protected drug class.

However, plans can make certain formulary changes, so it's important to review your coverage each year. If a medication is affected, you may have options such as exceptions, appeals, and temporary transition supplies.

My advice: Never assume your medication will automatically remain covered. Check your plan before making a change, and never stop treatment without talking to your doctor.

Susan Ramirez · Answer

Yes Medicare part D plans are required to cover HIV medications. Can the plan remove HIV medications, Yes but only under limited circumstances and Medicare's formulary - change rules.

Mary Brown · Answer

Yes, Medicare Part D plans must cover HIV medications. HIV medications fall under Medicare's six protected drug classes.

Kristen Skinner · Answer

You would need to look them up on the formulary to make sure they are covered. If they are not you can file an appeal to see if they can be covered. And yes, they can drop from the formulary.

Cindy Hoppe · Answer

It depends on your carrier. Review with your carrier or agent at AEP every year. It is a must. The carrier can drop if they want. This is why they have AEP.

Will my Medicare Part D plan cover my HIV medications, and can the plan drop them from its formulary?

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Will my Medicare Part D plan cover my HIV medications, and can the plan drop them from its formulary?

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