Medicare Part D has many pitfalls for HIV/AIDS patients

Here are some common problems

As if HIV clinics and physicians didn't have enough government paperwork and bureaucracy to worry about, the nearly three-year-old Medicare Part D prescription drug coverage offers a labyrinth of obstacles, pitfalls, and other problems in keeping HIV patients adherent to their antiretroviral treatment (ART).

For example, most Medicare recipients have to pay a co-pay that could be 20%, plus a monthly premium, and a deductible that changes each year, says Christopher A. Douglas, JD, staff attorney with the Legal Aid Society of San Mateo County in California.

Then there's the infamous doughnut hole: "Once you go into the doughnut hole you are responsible for 100% of the drug costs," Douglas says.

"So if the drug you were taking costs $500, then you have to pay $500 for it," he says.

A new analysis by the Kaiser Family Foundation in Washington, DC, has found that about 26 % of Medicare Part D prescription drug enrollees in 2007 reached the coverage gap or doughnut hole. This includes 22% who never got out of the hole for the rest of the year and 4 % who received catastrophic coverage.1

About one-fifth of the Part D enrollees who reached the coverage gap in 2007 stopped taking their medication in that drug class (about 15%), or reduced their medication use, or switched to a different medication in that class when they reached the gap.1

In addition, the analysis found that for some Medicare Part D enrollees, their monthly out-of-pocket spending nearly doubled during the coverage gap period. After a Medicare recipient pays roughly $3,500 in out-of-pocket medication costs while in the doughnut hole, then he or she enters the catastrophic coverage phase and Medicare Part D picks up more of the costs again.

"For a lot of people who are very sick, they'll get to the doughnut hole very quickly," Douglas says.

Often Medicare recipients will not realize they have reached the doughnut hole or even know that the doughnut hole exists until they show up at their pharmacy and are given a huge bill for their medications, Douglas says.

"The lack of understanding about Medicare Part D is so pervasive that in a good amount of the cases I see, people come in and think they've lost their coverage when they're in that doughnut hole," he explains. "They show up at the pharmacy, and the pharmacist says, 'You owe us $1,100,' and they don't know what's going on."

For many HIV-infected patients, there is more financial assistance under Medicare Part D, if they are Medicaid eligible, but they still might be faring worse than they were before Part D was enacted in 2006.

Two years ago, many of these same Medicare Part D patients might have received their ARTs uninterrupted from funding through the AIDS Drug Assistance Program (ADAP).

But now they have to be enrolled in Medicare Part D, and when they reach the doughnut hole, ADAP can begin paying for their medications, but only if all of the paperwork has been completed correctly.

For many low-income HIV patients this has not worked very well, says Moupali Das-Douglas, MD, MPH, an assistant clinical professor at the University of California - San Francisco (UCSF) and director of research in HIV in San Francisco, CA.

"In some states, ADAP is kicking in for the doughnut hole, but you have to have a really good social worker or legal advocate who can help patients do this, so a lot of people go without their drugs," Das-Douglas explains.

For many low-income HIV patients even the smallest of co-pays are unaffordable, Das-Douglas says.

"Economists and insurance people talk about it and say that a $5 co-pay for medications is great," Das-Douglas says.

"But for our patients, if they're paying $5 per medication, and they're on 10 medications per month, then a $50 co-pay is a big deal," she explains. "It's the difference between eating for a couple of days per week or paying for their medications."

Also, for these people, the other problem is that some of the antiretroviral drugs they were taking under ADAP might not be on the Medicare Part D formulary, and there have been no solutions offered to HIV patients when this occurs, Douglas says.

"The program I work in provides health access," Douglas says. "We help individual beneficiaries having problems navigate the system and get their needed medications."

The best solution for HIV providers and HIV patients would be if Medicare Part D would go away and a new and simpler plan with the ability to negotiate drug prices would be enacted, Douglas says.


  1. Hoadley J, Hargrave E, Cubanski J, et al. The Medicare Part D coverage gap: costs and consequences in 2007. The Medicare Drug Benefit by the Kaiser Family Foundation. August 2008:1-11.