HIV Meds Covered Under Insurance?

[Josh1959]

I’ve been diagnosed and undetectable since 2014. I’m about to begin Medicare in January. I’m really surprised that drug companies don’t offer discounts on copays when on Medicare like they do with commercial insurance. Today, I pay nothing as a copay. Starting in January, I’ll be paying $175 USD per month. This seriously cuts in on my social security funds.

Is this also your experience? I would say I am lower middle class, but this seriously stings.

[757pozzybear]

Are you also eligible for Medicaid or ADAP? That should help pay for the copay if eligible.

[Person]

1 hour ago, Josh1959 said:

I’ve been diagnosed and undetectable since 2014. I’m about to begin Medicare in January. I’m really surprised that drug companies don’t offer discounts on copays when on Medicare like they do with commercial insurance. Today, I pay nothing as a copay. Starting in January, I’ll be paying $175 USD per month. This seriously cuts in on my social security funds.

Is this also your experience? I would say I am lower middle class, but this seriously stings.

Is that your drug copay or your Medicare coverage copay. Everyone on Medicare has a fee deducted from their social security every month that has nothing to do with their prescriptions 

[Versholefun]

I’ve had the same Blue Cross coverage through employer for 20 years. Two years ago diagnosed with AIDS and prescribed Biktarvy with my copay being 530.00 per month.  January 2025 switched to Medicare with copay of 0.00 per month.

[PozBearWI]

Yes, starting in January I'll pay my max drug copay of $2,100.  After that I won't pay for any of my meds for the rest of the year.  For 26 my advantage plan is offering to spread the $2,100 out over the 12 months.  

[NakedPig]

Ryan White program.  You pay nothing for your meds.  [think before following links] https://ryanwhite.hrsa.gov/

[Josh1959]

On 11/3/2025 at 8:31 AM, PozBearWI said:

Yes, starting in January I'll pay my max drug copay of $2,100.  After that I won't pay for any of my meds for the rest of the year.  For 26 my advantage plan is offering to spread the $2,100 out over the 12 months.  

This is my exact experience.  I paid $1500 in January and $600 in February hitting my Medicare out of pocket max. It just shocks me that prior, with United Healthcare, I paid zero.

[PozBearWI]

Not sure why you would be shocked Josh.  

[Erik62]

My heart goes out to all you guys 🥰🥰🥰. This whole system is unacceptable & despite my complaints about Australia in general, our health coverage (Medicare) is pretty damn good. Each drug prescribed will cost approximately $8.00 & when we reach approximately $250.00 for pensioners (disabled, aged, unemployed, carers) it is free for rest of year & for "normal" people drug prescription costs are the same but the ceiling is approximately $500.00. The PBS (Pharmaceutical Benefits System) covers many of the most essential drugs, antibiotics, HIV/AIDS, Asthma, cancer, Parkinsons, Diabetes & a multitude of other very costly drugs. Generic drugs are usually dispensed but, the original brand can be received & the cost above BPS is born by patients. No system is perfect because some vital drugs (cancer etc) are not listed & the costs are truly prohibitive but the important fact is that many, many people are surviving because our Federal government subsidies our life saving medicines. Some of my HIV meds costs upwards of $2,500/bottle & I would have no way to me meet those costs, I would have been dead 35+ years ago. God Bless Medicare & the PBS🙏🙏. 

[Olderkinkybiguy]

Our healthcare system definitely sucks. I still take both Sustiva and Epzicom, I have for years. My Medicare replacement covers them, but my co-pay through insurance is about $200 a month. I used to get a 90 day supply for just under $600 but the pharmacy I was using said my insurance would only cover 30 days at a time. That really sucks if I want to travel. I recently switched to the online pharmacy, cost plus. I don’t go through my insurance and I am now receiving a 90 day supply for about $160. Back when I was using my RX coverage, my insurance was only covering about $8 of the total cost. I have found it’s sometimes cheaper to not use insurance when filling my perscriptions.. One time I had a script for something, don’t remember what the medication was, but my co-pay was a standard $10, but the actual cost without insurance was less than $2. It pays to shop around. 

[NWUSHorny]

I'm still a few years away from Medicare, but down to single digits. I'm currently paying a $100 month copay for Triumec. I'm having the same problem as @Olderkinkybiguy that United Healthcare will only pay for a 30 day supply and will only refill a few days early, my travel schedule hasn't put me in a position where I had to get the prescription transferred to where ever I'm working or vacationing yet, but have had to wait until the night before I leave or go to the pharmacy on the morning of my return several times a year for the last 2 year. Prior to that I was getting a 90 day supply and could get it 2 weeks early when I needed to.

My ID doc and I discussed the injectable option, but decided it wasn't really an option given my work travel schedule.

Edited Monday at 05:50 AM by NWUSHorny

[Erik62]

20 minutes ago, NWUSHorny said:

I'm still a few years away from Medicare, but down to single digits. I'm currently paying a $100 month copay for Triumec. I'm having the same problem as @Olderkinkybiguy that United Healthcare will only pay for a 30 day supply and will only refill a few days early, my travel schedule hasn't put me in a position where I had to get the prescription transferred to where ever I'm working or vacationing yet, but have had to wait until the night before I leave or go to the pharmacy on the morning of my return several times a year for the last 2 year. Prior to that I was getting a 90 day supply and could get it 2 weeks early when I needed to.

My ID doc and I discussed the injectable option, but decided it wasn't really an option given my work travel schedule.

Medicare is a universal system that pays a set amount to GP's, Specialist or Ancillary services physio, OT, Dietitian etc & covers entire population. Some of these services charge well above government co payment & patient makes up the rest ie: my Dermatologist charges $140.00 & government (Medicare) reimburses me $43.00. My physio & access to a University gym costs me $7,50/visit. It is also optional for private health insurance but it is questionable whether cost is worth it, I can't stand being in a hospital room by myself & I can sleep 😴 💤💤 through those who snore 😅😅but, the pros of Public Health Care (usually) beat the cons (waiting lists for a hip replacement). 

[NWUSHorny]

In the US Medicare is the government insurance program for people 65 and over, unfortunately Medicare does not cover prescription drugs, those are covered by private supplement plans that change what they cover annually, and seniors have to try to figure which ones will cover what they know they will need, and guess at what they might need, at a cost they can afford for the next year. Which really sucks for our senior citizens.

I'm in my late 50's so have witnessed my parents trying to lookup all of their meds in the plan details and try to figure out which plan is the best value for the next year during the annual enrollment period.

[Pozzible]

1 hour ago, NWUSHorny said:

In the US Medicare is the government insurance program for people 65 and over, unfortunately Medicare does not cover prescription drugs, those are covered by private supplement plans that change what they cover annually, and seniors have to try to figure which ones will cover what they know they will need, and guess at what they might need, at a cost they can afford for the next year. Which really sucks for our senior citizens.

Well, under Biden a law was enacted that capped the yearly total cost of drugs for Part D participants at $2000 for the entire year. It was terrific! I believe I was told that the cap will be about &2200. Which is still great! I think that’s for all enrolled in Part,D supplement plans. Medicare Advantage is a whole different animal.

[PozBearWI]

On 11/3/2025 at 8:53 AM, NakedPig said:

Ryan White program.  You pay nothing for your meds.  [think before following links] [think before following links] https://ryanwhite.hrsa.gov/

Unfortunately a whole lot of us don't qualfiy