North Carolina Marketplace Plans with More Affordable Drug Cost Sharing for People with HIV

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1 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 plans are potentially affordable for people who take ARV s. This is because ARVs are far less costly on most 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 plans that have lower drug cost sharing for people using ARVs. Important features of the plans listed below: o Drug cost sharing: The formulary places most ARVs on tiers 3 and 4. For these tiers, drug costs are by copay, and in most plans drugs are not subject to a. This means patients can purchase drugs with a copay on day 1. Other plans in the NC Marketplace require that the patient meet a 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 (except Bronze 5000 plan). o Labs and imaging: Patient must first meet. After, 20-30% coinsurance. o Availability: plans are available in all counties. o Provider networks: 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 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 eligible for tax credits. Reduced Cost Sharing: People with incomes between 100% and 250% FPL may be eligible for lower s, 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 and out of pocket maximum. For details about these and other plans, check healthcare.gov. For a side-by-side comparison, see

2 Plan Name Monthly Premium Range (varies based primarily on age) Deductible not subject to Other key features Out of pocket maximum Drug Copays/ Coinsurance Silver Cost Sharing Reduction Plans (94%) For incomes % FPL ($11,490 - $17,235 for single) Silver Enhanced Silver Enhanced $72 - $197 $500 individual $1000 family $76 - $191 $500 individual $1000 family ER copay $100 $700 individual/ $1400 family $700 individual/ $1400 family Silver Cost Sharing Reduction (87%) For incomes % FPL ($17,235 - $22,980 for single) Silver Enhanced $103 - $240 $1000 individual $2000 family ER copay $100 $2000 individual/ $4000 family

3 Plan Name Silver Enhanced Monthly Premium Deductible Range (varies based primarily on age) $115 - $255 $1000 individual $2000 family not subject to Other key features Out of pocket maximum $1900 individual/ $3800 family Drug Copays/ Coinsurance Silver Cost Sharing Reduction (73%) For incomes % FPL ($22,980 - $28,725 for single) In most cases, patients in this income group may do better with a Platinum plan Silver Enhanced $136 - $332 $2700 individual $5400 family $4900 individual $9800 family Silver Enhanced $130 - $261 $3000 individual $6000 family First 4 PCP Visits; Specialist Visit; ER Visit; Urgent $5200 individual $10,400 family

4 Plan Name Silver Enhanced Monthly Premium Deductible Range (varies based primarily on age) $185 - $327 $3500 individual $7000 family not subject to Other key features Out of pocket maximum $5000 individual $10,000 family Drug Copays/ Coinsurance Silver Enhanced $173 - $313 $4500 individual $9000 family $5200 individual $10,400 family 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) Platinum 500 Age 27: $329 - $399 Age 50: $561 - $679 $500 individual $1000 family ; Rx Tier 1-4 labs, imaging, etc: 20% $1500 individual $3000 family Tier 1 - $4 Tier 2 - $10 Tier 3 - $30 Tier 4 - $50

5 Plan Name Monthly Premium Range (varies based primarily on age) Deductible not subject to Other key features Out of pocket maximum Drug Copays/ Coinsurance Gold Plan Gold 1000 Age 27: $293 - $355 Age 50: $499 - $605 $1000 individual $2000 family PCP Visit; Specalist ; Rx Tier 1-4 PCP visit $15 copay; specialist $30/copay, 1 st visit. Then $500 labs, imaging, etc: 20% $4000 individual $8000 family Tier 3 - $45 Tier 4 - $65 Silver Plans Silver 2800 Silver 3500 Age 27: $243 - $294 Age 50: $414 - $501 $2800 individual $5600 family $3500 individual $7000 family PCP visit $30 copay; Specialist $60/copay, 1st visit. Then $500 PCP visit $25 copay; specialist $50/copay, 1st visit. Then $500 $6350 individual $12,700 family $6350 individual $12,700 family

6 Plan Name Silver 5000 Monthly Premium Range (varies based primarily on age) Age 27: $239 - $289 Age 50: $407 - $493 Deductible $5000 individual $10,000 family not subject to Other key features PCP visit $25 copay; specialist $50/copay, 1st visit. Then $500 Out of pocket maximum $6350 individual $12,700 family Drug Copays/ Coinsurance Bronze Plan May be most cost effective option for older clients, especially after age 55, but does have a high Bronze 5000 Age 27: $206 - $250 Age 50: $352 - $426 $5000 individual $10,000 family First 4 PCP Visits; Rx Tiers 1-4 PCP visit $45; Specialist 20% coinsurance (after ), 1st visit. Then $500 labs, imaging, etc: 20% $6350 individual $12,700 family Tier 1 - $25 Tier 2 - $35 Tier 3 - $75 Tier 4 - $100

7 ADAP Formulary Compared to ADAP Tier 1 Tier Agenerase (Amprenavir) Not on formulary Aptivus (Tipranavir) 3 Atripla (Efavirenz, Emtricitabine, Tenofovir) 3 Combivir (Zidovudine and lamivudine) 4 Complera (Rilpivirine, Emtricitabine, Tenofovir) 3 Crixivan (Indinavir) 3 Edurant (Rilpivirine) 3 Emtriva (Emtricitabine) 3 Epivir (Lamivudine 3TC) - tab 4/3 Epzicom (Abacavir and Lamivudine) 3 Fuzeon (Enfuvirtide) 4 Intelence (Etravirine) 3 Invirase (Saquinavir) 3 Isentress (Raltegravir) 3 Kaletra (Lopinavir and Ritonavir) 3 Lexiva (Fosamprenavir) 3 Norvir (Ritonavir) 3 Prezista (Darunavir) 3 Prezista (Darunavir) - susp 100 mg/ml 5 Rescriptor (Delavirdine) 3 Retrovir (Zidovudine AZT) - cap 100 mg 5/4 Reyataz (Atazanavir) 5 Selzentry (Maraviroc) 3 Stribild (Elvitegravir, Cobicistat, Emtricitabine, Tenofovir) 3 Sustiva (Efavirenz) 3 Tivicay (dolutegravir) 4 Trizivir (Zidovudine, Lamivudine, 3 ADAP Formulary Compared to ADAP Tier 1 Tier Abacavir) Truvada (Tenofovir and Emtricitabine) 3 Videx (Didanosine ddi) 3 Viracept (Nelfinavir) 3 Viramune, Viramune XR (Nevirapine) 4/3 Viread (Tenofovir) 3 Zerit (Stavudine d4t) 4 Ziagen (Abacavir) 4/3 Aptivus (Tipranavir) 3 Atripla (Efavirenz, Emtricitabine, Tenofovir) 3 Combivir (Zidovudine and lamivudine) 4 Complera (Rilpivirine, Emtricitabine, Tenofovir) 3 Crixivan (Indinavir) 3 Edurant (Rilpivirine) 3 Emtriva (Emtricitabine) 3 Epivir (Lamivudine 3TC) - tab 4/3 Epzicom (Abacavir and Lamivudine) 3 Fuzeon (Enfuvirtide) 4 Intelence (Etravirine) 3 Invirase (Saquinavir) 3 Isentress (Raltegravir) 3 Kaletra (Lopinavir and Ritonavir) 3 Lexiva (Fosamprenavir) 3 Norvir (Ritonavir) 3 Prezista (Darunavir) 3 Prezista (Darunavir) - susp 100 mg/ml 5 Rescriptor (Delavirdine) 3

8 ADAP Formulary Compared to ADAP Tier 1 Tier Retrovir (Zidovudine AZT) - cap 100 mg 5/4 Reyataz (Atazanavir) 5 Selzentry (Maraviroc) 3 Stribild (Elvitegravir, Cobicistat, Emtricitabine, Tenofovir) 3 Sustiva (Efavirenz) 3 Tivicay (dolutegravir) 4 Trizivir (Zidovudine, Lamivudine, Abacavir) 3 Truvada (Tenofovir and Emtricitabine) 3 Videx (Didanosine ddi) 3 Viracept (Nelfinavir) 3 Viramune, Viramune XR (Nevirapine) 4/3 Viread (Tenofovir) 3 Zerit (Stavudine d4t) 4 Ziagen (Abacavir) 4/3 ADAP Tier Ancobon (Flucytosine) 4 Bactrim, Septra, Cotrim, Sulfatrim (Sulfadiazine Sulfamethoxazole/trimethoprim) 4/1 Biaxin (Clarithromycin) 4/2 Cleocin (Clindamycin) 4/1 Cytovene (Ganciclovir) 5 Daraprim (Pyrimethamine) 4 Diflucan (Fluconazole) 4/1 Famvir (Famciclovir) 4/2 Foscavir (Foscarnet) Fungizone (Amphotericin B) 4/3 Myambutol (Ethambutol) 4/2 ADAP Tier Mycobutin (Rifabutin) 4 Mycostatin, Nilstat (Nystatin) 4/1 NebuPent, Pentam (Pentamidine) 4 Nydrazid (Isoniazid, INH) 4/3/1 Pegasys (Peginterferon alfa 2a) 4 Peg-Intron (Peginterferon alfa 2b) 4 Prednisone 4/3/1 Probenecid (Probenecid) 1 PZA (Pyrazinamide) 4 Rifadin, Rimactane (Rifampin) 4/2 Sporanox (Itraconazole) 4/2 Valcyte (Valganciclovir) 4 Valtrex (Valacyclovir) 4/2 Virazole, Rebetol, Copegus (Ribavirin) 5/2 Vistide (Cidofovir) Wellcovorin (Leucovorin) 4/3/2 Zithromax (Azithromycin) 4/1 Zovirax (Acyclovir) 4/1 Tier 1 B Avelox B (Moxifloxacin) 3 Aventyl, Pamelor (Nortriptyline) 4/1 Cipro (Ciprofloxacin) 4/1 Compazine (Prochlorperazine) 1 Creon (Pancrelipase) 3 Dapsone (Dapsone, DDS) 3 Desyrel (Trazodone) 1 Dilantin (Phenytoin) 3/1 Doryx, Vibramycin, Vibra-Tabs (Doxycycline hyclate) 4/2/1 Dronabinol (Marinol) 2 Elavil (Amitriptyline) 1 Epogen, Procrit (Erythropoietin) 5 Flagyl (Metronidazole) 4/2/1 Humatin (Paromomycin) 4/2

9 ADAP Tier Hydrea (Hydroxyurea) 4/1 Imodium (Loperamide) 4/1 Keppra (Levetiracetam) 4/2/1 Levaquin (Levofloxacin) 4/2 Lomotil (Diphenoxylate w/atropine) 4/1 Megace (Megestrol) 4/1 Mepron (Atovaquone) 4 Minocin,Dynacin (Minocycline) 4/1 Neupogen (Filgrastim) 4 Neurontin (Gabapentin) 4/1 Nizoral (Ketoconazole) 4/2/1 Phenergan (Promethazine) 1 Prevacid (Lansoprazole) 4/2 Prilosec (Omeprazole) 4/1 Primaquine (Primaquine) 4/3 Prozac (Fluoxetine) 4/2/1 Remeron (Mirtazapine) 4/1 Zofran (Ondansetron Hydrochloride 4/2/1 Tier 2 Androgel, Testim Androderm (Testosterone) 4/3 Lotensin (Benazepril) 4/1 Aldara (Imiquimod) 4/2 Luminal (Phenobarbital) 4/1 Amoxil (Amoxicillin) 1 Lyrica (Pregabalin) 3 Baraclude (Entecavir) 4 Metformin (Glucophage) 4/1 Bicillin LA (Penicillin G Benzathine) Mevacor, Altoprev (Lovastatin) 4/1 Calan, Isoptin (Verapamil) 4/1 Mycelex Troches (Clotrimazole 1 ADAP Tier Troches) Catapres (Clonidine) 4/1 Norvasc (Amlodipine) 4/1 Celexa (Citalopram) 4/1 Paxil (Paroxetine) 4/1 Chantix B (Varenicline) 3 Pravachol (Pravastatin) 4/1 Crestor (Rosuvastatin) 3 Reglan (Metoclopramide) 4/1 Depakote (Divalproex) 4/1 Sinequan (Doxepin) 4/3/2/1 Effexor, Effexor XR (Venlafaxine) 4/1 Tegretol, Carbatrol (Carbamazepine) 3/2/1 HCTZ (Hydrochlorithiazide) 1 Tenormin (Atenolol) 4/1 Hepsera (Adefovir) 4/2 Tricor, Lofibra (Fenofibrate) 4/2/1 Infergen (Interferon Alfacon-1) 4 Trilipix (fenofibric Acid) 4/2 Intron A (Interferon Alfa-2a) 3 Vasotec (Enalapril) 4/1 Keflex (Cephalexin) 4/1 Veetids, V-Cillin-K (Penicillin VK) 1 Lexapro (Escitalopram) 4/2 Wellbutrin (Bupropion) 4/1 Lipitor (Atorvastatin) 4/2 Zestril, Prinivil (Lisinopril) 4/1 Lopid (Gemfibrozil) 4/1 Zetia (Ezetimibe) 3 Lopressor, Toprol (Metoprolol) 4/1 Zoloft (Sertraline) 4/1

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