Hands Off Medicare Part D

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Hands Off Medicare Part D
Proposed changes to access to lifesaving meds would have killed us
by Hank Trout

Last month, I filmed a PSA about the devastating changes the Trump-Pence cabal have proposed for Medicare Part D, the prescription drug coverage under Medicare. The PSA is one in a series produced by the San Francisco AIDS Foundation and Precision Strategies out of New York City featuring real Medicare recipients talking about the effects the proposed changes would have on our lives.

Fortunately, on May 16, 2019, the administration said that it would maintain existing policy for HIV drugs and not allow plans to institute prior authorization and step therapy in the Medicare Part D program. Carl Schmid, Deputy Executive Director of The AIDS Institute, issued the following statement:

“We are pleased that Secretary Azar and the Trump Administration listened to the patients and widely accepted HIV treatment guidelines by rejecting their proposal to institute prior authorization and step therapy for HIV drugs for the first time in the Medicare Part D Program. At a time when the Administration is focused on ending the HIV epidemic in the United States by increasing access to HIV drugs for treatment and prevention, allowing such bad medicine would not have made sense.”

Under current rules, all Part D prescription insurance plans must cover all drugs from six protected classes on their formularies. Those classes are: antidepressants; antipsychotics; anticonvulsants; immunosuppressants for treatment of transplant rejection; antineoplastics; and of utmost important to us HIV-positive long-term survivors, antiretrovirals. Under the guise of reducing prescription costs, the proposed rule would have allowed Part D sponsors to: 1) implement broader use of prior authorization (PA) and step therapy (ST) for protected class drugs; 2) exclude a protected class drug from a formulary if the drug is merely a new formulation of an existing single-source drug or biological product, regardless of whether the older formulation remains on the market; and 3) exclude a protected class drug from coverage if the price of the drug increases beyond the Consumer Price Index for all Urban Consumers (CPI-U) in comparison to a baseline month and year.

Medicare Part D has been instrumental in the fight against HIV/AIDS, ensuring access to life-saving medications for PLHIV who otherwise could not afford them. It created a protected class of drugs that ensured enrollees living with serious, chronic and, in the case of HIV, infectious health conditions, can directly access the best treatments as prescribed by their medical providers. The proposed changes would have eliminated medications from this protected class status of drugs for approximately 45 million people receiving drug coverage through Medicare Part D, including over 250,000 people living with HIV.

The changes would have allowed Part D insurers to exclude a protected class drug, such as antiretrovirals, when the price for the drug rises faster than inflation. This would have empowered providers to stop covering more expensive HIV treatments and would have discouraged pharmaceutical companies from creating new medications.

The most dangerous aspect of the proposed changes is that the proposal would have encouraged “step therapy,” forcing people PLHIV to try older, less effective, but lower-cost treatments first, crossing your fingers that they work, rather than the treatment their physician deems most effective. The proposed “try-the-cheap-stuff-first-and-see” step therapy approach would have enabled insurers to force newly diagnosed patients to start treatment using older, less efficient, less expensive medications to see if they work before changing to newer, more expensive, more effective alternatives, ignoring what your doctor has determined is the best treatment for you. It would also have enabled insurers to force HIV-positive Medicare recipients who are already on successful antiretroviral regimens to change those regimens to include cheaper medications which might not work.

It is no exaggeration to say that these proposed changes could have killed some of us.

When SFAF and Precision Strategies approached me to record this PSA in opposition to the proposed changes, I leapt at the chance. Although my HIV medications are covered through ADAP (the AIDS Drug Assistance Program), I rely on Medicare Part D to cover a bucketful of other prescriptions that I take. Those medications—for arthritis, emphysema, osteoporosis, asthma, COPD, chronic pain, fatigue, and depression—are all covered by Medicare Part D. The proposed changes would have made those medications prohibitively expensive for me. If “prior authorization” and “step therapy” are applied to those medications, I could lose them altogether.

While I celebrate the Administration’s decision not to institute these rule changes, I am horrified that the changes were ever even considered. I cannot help thinking that the only real reason for the proposed changes was to punish those of us who are long-term HIV survivors. And that makes me mad as hell!


Hank Trout, Senior Editor, edited Drummer, Malebox, and Folsom magazines in the early 1980s. A long-term survivor of HIV/AIDS (diagnosed in 1989), he is a forty-year resident of San Francisco, where he lives with his fiancé Rick. Follow him on Twitter @HankTroutWriter.