I'm working my way through the maze at www.medicare.gov, trying to figure out which plans cover what in Texas. I decided to start with the Texas HIV Medication Program formulary and see what plans covered those drugs. The whole thing is a tad tedious, but well worth it in the end (not that I am anywhere near the end of typing in the whole list).
Once you type in a group of drugs, the Medicare web site will search through all of the plans in your area to see who provides them and what it will cost you in a month or over a year. You can then click on each plan to get the details of what those costs are.
I thought it was interesting that, when I typed in all of the protease inhibitors on the THMP formulary, there was significant difference in cost between the plans. There is supposed to be a limit to the out-of-pocket costs that someone pays once catatrophic coverage has been reached. Some of the totals were well beyond what I thought it would be, so I started clicking to find out more.
As it turns out, while most of the plans seem to include all of the protease inhibitors on the THMP list, some of them don't. Just for an example, Wellcare Signature would provide all of these drugs (not that anyone would be taking all of them at the same time) for an estimated annual cost of $7,401. Drilling down a bit, it turns out that a hefty chunk of that cost comes from a single drug, which is not on their formulary.
When a drug that you might need is not on a plan's formulary, you will have to pay the full cost of the drug, rather than the 25 percent co-pay that you might pay for other drugs. What's more, the amount that you pay for this drug will not count toward your out-of-pocket costs in determining when catastrophic coverage will begin. Once catastrophic coverage begins, you are still stuck paying the full price for this drug.
Regardless of the plan and regardless of the drug, the point is that you should check each plan carefully for its coverage of the medications that you are taking. You should also be alert to any changes in the plan's formulary and be prepared to challenge the plan regarding the medical necessity of your medical regimen. Easier said than done, I know, but still worth saying.