Bay Area Reporter - December 8, 2005
Matthew S. Bajko, m.bajko@ebar.com

Under the new program, most seniors have been told they can wait until May 15, 2006 to choose from the dozens of plans insurance companies are offering under Part D. But for Medicare and Medi-Cal participants who have HIV or AIDS, advocates advise they should be signed up within the next three weeks.

"Everybody needs to pick a plan by January 1. The reason why everyone with HIV needs to sign up for ADAP by January 1 is ADAP is going to help people pay their deductibles and copayments. It is something we were able to get the governor to agree to before last year's budget," said Dana Van Gorder, director of local and state affairs for the San Francisco AIDS Foundation. "In order for those to occur you need to pick a plan and get prescription drugs from ADAP. If you don't pick a plan, ADAP can't help."

In California, 18,000 people with HIV or AIDS are affected by Part D. Out of the nearly 50 plans being offered, it is impossible to determine which ones would be best for PWAs or if the plan they have been randomly assigned by the government is best for them.

"Theoretically, every single plan should have all retrovirals on it. There should not be a plan out there that is absolutely horrible for persons with HIV. On the other hand, there will be many that will be inadequate," said Anne Donnelly, director of public policy for Project Inform. "One issue is if the plans don't cover the drugs you are taking."

In choosing a plan, people with HIV or AIDS should make sure it covers all the medications they are currently taking, as well as those they have taken in the past, said Van Gorder.

A plan finder can be found at www.medicare.gov and allows people to type in up to 25 medications at a time to see which plans cover the drugs. To use it, click on the Compare Medicare Prescription Drug Plans option. Put in your personal information and then enter your medications.

Donnelly warned that users need to have the exact brand name, dosage, and quantities for each medicine. The system will also ask how a drug presents - meaning if it is in tablet from or injected.

"Once you put that in, it will start telling you what plans will cover your drugs," she said. "Then you have to use what is called the formulary finder, which is a different tool, and reenter your drugs again."

However, not all the information is accurate, and Donnelly advised people to call the plan providers directly to verify if the drugs are covered.

She also noted that some of the plans indicate people need to fail a drug protocol - known as step therapy - before they are allowed to switch to a new one. However, she said, "that is not allowed with the HIV drugs. We know it is a mistake."

Van Gorder advised people to also check to see if the plan uses the pharmacy they want to go to and that the pharmacy is in the ADAP network.

"This should not be much of an issue in San Francisco but it could be in rural areas," he said.

The plans vary so much that each individual needs to decide based on their own circumstances what plan to select. For people who are dual eligibles, meaning they receive their primary medical care from Medicare and their prescription drugs from Medi-Cal, they need to sign up for a zero cost plan.

"If the plan is very difficult with its in-house appeals process, that is bad for HIV people," who need to petition to have a drug covered, he said.

The AIDS foundation and Project Inform are co-sponsoring a community briefing about Part D next week to help Medicare eligible individuals with HIV and AIDS understand the new program and the steps they must take prior to January 1, 2006 to prepare for it. Additionally, the two agencies have produced a set of three brochures describing how Part D works, how it interacts with Medi-Cal and ADAP, and how individuals can take steps to prepare for its implementation on the first of the new year.

One brochure describes the standard Part D benefit and its interaction with ADAP. The second brochure describes the Part D benefit and its interaction with ADAP for low-income individuals who may be eligible for assistance with out of pocket expenses imposed by the Part D program. The final brochure describes the Part D benefit for individuals who are eligible for both Medicare and Medi-Cal.

The brochures are available in English and Spanish and can be downloaded at www.sfaf.org/policy/medicare or www.projectinform.org/org/medicare/partd.html.

The meeting will take place from 6 to 8 p.m. Monday, December 12 at the Everett Middle School Auditorium, 450 Church Street (between 16th and 17th streets) in San Francisco.

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Always watch for outdated information. This article first appeared in 2005. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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