Important note: Information in this article was accurate in 2007. The state of the art may have changed since the publication date.
Bay Area Reporter - December 13, 2007
Heather Cassell, h.cassell@ebar.com
The apparent problem is that the plan finder isn't always current, especially with drugs newly approved by the Food and Drug Administration, like Isentress (raltegravir), which was approved October 12, according to Courtney Mulhern-Pearson, policy analyst of the San Francisco AIDS Foundation, and Anne Donnelly, director of health care advocacy of Project Inform.
Medicare's open enrollment period deadline is December 31 for 2008 health care coverage.
Donnelly told the Bay Area Reporter that in spite of a drug not appearing on a Medicare Part D drug plan formulary it doesn't mean that the drug isn't included in the individual plan.
"Individual private plans are required to cover these drugs," said Donnelly. "We actually want to know from folks if they really find a plan where it's not covered, even if it is a new drug and it doesn't have protected status, because we still can have some leverage on that. A person can file an exception to get access to that drug, so we always want to know. But the fallback is that ADAP is going to take care of them if there is a glitch or a problem or something like that."
The AIDS Drug Assistance Program approved Isentress for coverage November 21, according to Lea Brooks, spokeswoman for the California Department of Public Health.
Medicare representatives did not respond to a request for comment.
According to Donnelly, the process for drugs appearing on individual Medicare Part D plan formularies is lengthy if the FDA approves a drug after April of each year. Drug plans have 90 days after a medication is approved by the FDA prior to April of each year to be included in the formularies as a protected class. If drugs are approved after April it can take up to a year and a half for drugs in a protected class to appear in a plan. HIV/AIDS drugs are a protected class.
But Donnelly hasn't seen very many instances where AIDS medications haven't been covered after the FDA approves them. They "generally get inclusion pretty quickly," she said.
"We haven't seen a whole lot of trouble that we are aware of with drugs of this kind being covered," said Donnelly.
SFAF hasn't been alerted to any problems either, according to Mulhern-Pearson and Ellen Novogrodsky, a SFAF financial benefits counselor. Mulhern-Pearson told the B.A.R. that some of the foundation's clients were already receiving Isentress through Medicare Part D plan providers.
"The best way to compare plans for a person living with HIV/AIDS is to compare their drugs that aren't on ADAP," said Donnelly. "It will make it much simpler and much clearer."
Mulhern-Pearson advised people to speak with a benefits counselor if they have questions about coverage. Novogrodsky also advised that it's a good idea to follow up with Medicare or the insurance provider after receiving the online enrollment confirmation to check to make sure enrollment applications have been processed.
For more information about the open enrollment period, Project Inform and the East Bay Community Law Center will present "Medicare Part D Update," today (Thursday, December 13), from 12:30 to 3:30 p.m. at the Office of AIDS Administration, Gary Harmon Conference Room, 1970 Broadway, 11th Floor, in Oakland (near 19th Street BART station). The event is free to the public and lunch will be served. To RSVP or for more information contact: support@projectinform.org.
For Medicare Part D health benefits assistance, see http://ebar.com/news/article.php?sec=news&article=2436 and scroll down for the list of contacts.
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