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Microsoft word - plans with workable drug copays-12-12-13

North Carolina Marketplace Plans
with More Affordable Drug Cost Sharing for People with HIV
Of North Carolina’s marketplace insurance offerings, only Blue Cross Blue Shield’s Blue Advantage plans are potentially affordable for people
who take ARV’s. This is because ARVs are far less costly on most Blue Advantage plans. Even though these plans are the most workable, they
will still be unaffordable for many, even with tax credits and cost sharing assistance. This chart lists Blue Advantage plans that have lower drug
cost sharing for people using ARVs.
Important features of the plans listed below:
o Drug cost sharing: The Blue Advantage formulary places most ARVs on tiers 3 and 4. For these tiers, drug costs are by copay, and
in most Blue Advantage plans drugs are not subject to a deductible. This means patients can purchase drugs with a copay on day 1. Other plans in the NC Marketplace require that the patient meet a deductible before accessing drug coverage, and place all ARVs on tier 5, with 25% - 40% coinsurance. o Doctor visits: Generally subject to a small copay for both primary care provider (PCP) and specialist. Can be accessed without
meeting the deductible (except Bronze 5000 plan). o Labs and imaging: Patient must first meet deductible. After deductible, 20-30% coinsurance.
o Availability: Blue Advantage plans are available in all counties.
o Provider networks: Blue Advantage has the widest provider network
o Premiums: Will vary primarily based on age, with a person aged 64 paying 3 times what is paid by a person aged 21. County of
residence also affects, cost, but to a smaller degree. Patients eligible for tax credits will be able to get lower premiums. Example premiums are listed below, but patients should check healthcare.gov and https://www.bcbsnc.com/assets/shopper/public/quote/#/ for exact rates for their age, income, and county of residence. o Subsidies:
Tax Credits: People with incomes between 100% and 400% of the poverty level ($11,490 - $45,960 for single) may be
Reduced Cost Sharing: People with incomes between 100% and 250% FPL may be eligible for lower deductibles, copays,
and coinsurance on a silver plan (called “Silver Enhanced” or “Cost Sharing Reduction Plan”). However, for most people over 200% FPL ($22,980), it may be most cost effective to choose the Platinum plan because it has a low deductible and out of pocket maximum.  For details about these and other plans, check healthcare.gov. For a side-by-side comparison, see http://tinyurl.com/NC-QHPs-2014 Prepared by Duke AIDS Legal Project, 12/12/2013 Plan Name
Monthly Premium
Deductible
Services not subject to Other key features
Out of pocket
Drug Copays/
deductible
Coinsurance
(varies based
primarily on age)

Silver Cost Sharing Reduction Plans (94%)
For incomes 100-150% FPL ($11,490 - $17,235 for single)
labs, imaging, etc: 30% coinsurance, after deductible labs, imaging, etc: 30% coinsurance, after deductible Silver Cost Sharing Reduction (87%)
For incomes 150-200% FPL ($17,235 - $22,980 for single)
labs, imaging, etc: 30% coinsurance, after deductible Prepared by Duke AIDS Legal Project, 12/12/2013 Plan Name
Monthly Premium
Deductible
Services not subject to Other key features
Out of pocket
Drug Copays/
deductible
Coinsurance
(varies based
primarily on age)

labs, imaging, etc: 30% coinsurance, after deductible Silver Cost Sharing Reduction (73%)
For incomes 200-250% FPL ($22,980 - $28,725 for single)
In most cases, patients in this income group may do better with a Platinum plan
labs, imaging, etc: 30% coinsurance, after deductible labs, imaging, etc: 30% coinsurance, after deductible Prepared by Duke AIDS Legal Project, 12/12/2013 Plan Name
Monthly Premium
Deductible
Services not subject to Other key features
Out of pocket
Drug Copays/
deductible
Coinsurance
(varies based
primarily on age)

labs, imaging, etc: 30% coinsurance, after deductible labs, imaging, etc: 30% coinsurance, after deductible Platinum Plan
Higher premium, lower cost sharing and out of pocket maximum.
May be the cheapest plan for people with incomes over 200% FPL ($22,980)
labs, imaging, etc: 20% coinsurance, after deductible Prepared by Duke AIDS Legal Project, 12/12/2013 Plan Name
Monthly Premium
Deductible
Services not subject to Other key features
Out of pocket
Drug Copays/
deductible
Coinsurance
(varies based
primarily on age)

Gold Plan
labs, imaging, etc: 20% coinsurance, after deductible Silver Plans
labs, imaging, etc: 30% coinsurance, after deductible labs, imaging, etc: 30% coinsurance, after deductible Prepared by Duke AIDS Legal Project, 12/12/2013 Plan Name
Monthly Premium
Deductible
Services not subject to Other key features
Out of pocket
Drug Copays/
deductible
Coinsurance
(varies based
primarily on age)

labs, imaging, etc: 30% coinsurance, after deductible Bronze Plan
May be most cost effective option for older clients, especially after age 55,
but does have a high deductible
Then $500 labs, imaging, etc: 20% coinsurance, after deductible Prepared by Duke AIDS Legal Project, 12/12/2013 ADAP Formulary Compared to Blue Advantage
ADAP Formulary Compared to Blue Advantage
ADAP Tier 1
Blue Advantage Tier
ADAP Tier 1
Blue Advantage Tier
Prepared by Duke AIDS Legal Project, 12/12/2013 ADAP Formulary Compared to Blue Advantage
Blue Advantage Tier
ADAP Tier 1
Blue Advantage Tier
Blue Advantage Tier
Prepared by Duke AIDS Legal Project, 12/12/2013 Blue Advantage Tier
Blue Advantage Tier
Benzathine) Mevacor, Altoprev (Lovastatin) Prepared by Duke AIDS Legal Project, 12/12/2013 Prepared by Duke AIDS Legal Project, 12/12/2013

Source: http://www.hivhealthreform.org/wp-content/uploads/2013/12/NC-Plans-with-workable-drug-copays-12-12-13.pdf

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