Prescription Drug Coverage


Anna's Story

Anna recently found out that she had HIV. After meeting with her doctor and hearing about all of the treatment options available, she realized that she was going to be taking a lot of prescription drugs. She had private health coverage through her job in Los Angeles, but she wasn’t sure how much that insurance plan would pay for. Anna did not feel comfortable telling her human resources department that she was HIV positive, so she simply asked for a copy of the policy. When she got home and started reading through it, she understood the basics of the policy, but wanted some help with the details. She decided to call a local organization that had expertise dealing with HIV/AIDS and benefits. She made an appointment to speak with one of their benefits planners, Alfonso. On the phone, he told her to bring a copy of the insurance policy.

At Alfonso’s office, Anna explained that she was most worried about how she would pay for her prescription drugs. Alfonso took a few minutes to carefully read through her policy. After he finished, he explained what he thought.

Alfonso said, “Most of the common HIV/AIDS drugs are covered by your plan. Your plan, however, has a $500 deductible and 20% co-insurance.”

When he noticed that Anna was beginning to look a bit confused, he explained that a deductible is a certain amount of money that you have to pay before insurance kicks in. “For example, let’s say that you get a prescription that costs $50 and is covered by your plan,” Alfonso said. “You’ll have to pay for the entire cost of that drug because you haven’t met your deductible yet. Once you’ve spent $500, the insurance will kick in.”

Anna asked, “And then they’ll pay for the entire cost of the drug?”

“No,” Alfonso replied, “that’s when the co-insurance starts. Your insurance company will pay for 80% of the cost of the drug, and you’ll have to pay the other 20%. There may, however, be help available for you to pay those costs. If you have less than $50,000 in Federal Adjusted Gross Income each year and meet other rules, you might be eligible for a program called the AIDS Drug Assistance Program (ADAP). It can pay for some or all of the costs for HIV/AIDS drugs, depending on how much income you have. You can find out how much your Federal Adjusted Gross Income is by looking at your tax returns.”

Anna laughed and said, “Well, I don’t know exactly what my tax returns say, but I’m positive it’s less than $50,000. How do I sign up?” Alfonso told her that the Office of AIDS coordinates the program in California. He explained that she could sign up at one of the approximately 250 enrollment sites in California. "You can call the local ADAP coordinator in your county to find an enrollment site in your area," Alfonso said.

Anna enrolled in ADAP and was able to have them pay the entire cost of her deductibles and co-insurance.

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