Private health coverage pays for part of your medical costs. These costs can include seeing doctors, having medical tests done, and getting medications. You get private health coverage either by paying a monthly premium directly to an insurance company or by enrolling in a group plan sponsored by your employer or your spouse’s or parent's employer. If you get an individual plan on HealthCare.gov, the government may also help pay a portion of your premium.

The details of what medical expenses your private health coverage will pay for depend on how your plan is set up. Different private health coverage plans will pay different amounts for different services in different situations. This means that when you go to the doctor, the hospital, or a pharmacy, your private health coverage will pay part or all of the cost of these services, depending on your plan.

If you don’t have private health coverage right now, these are the most common ways to get it:

1. Private health coverage is often offered as part of your compensation for work. You may also get it through a spouse's or parent's job. This employer-sponsored coverage varies greatly in terms of how much it will cost you and the extent of prescription coverage it includes.
2. Individual health coverage can be purchased for you and your family at HealthCare.gov. If you can't get employer-sponsored coverage and don't qualify for Medicare or AHCCCS, the government may help you pay your monthly premium through tax subsidies. Note: There is no income limit for getting subsidies that help pay individual coverage premiums. (Before 2021, the limit was 400% of FPG.) To get subsidies, you still must meet other eligibility rules and the premium amount you pay depends on your income and your plan.

For more details, read DB101’s articles on Employer-Sponsored Health Coverage and Buying Individual Health Coverage on HealthCare.gov.

AHCCCS is Arizona's Medicaid program. It helps pay medical expenses for people with low income. If you meet eligibility requirements, AHCCCS will help pay for your visits to the doctor, hospital stays, prescription drugs, medical equipment, and other medical services.

AHCCCS Prescription Benefits

Most AHCCCS beneficiaries pay a small $2.30 copayment for their prescription drugs.

You do not need to make copayments if you are:

• Less than 19 years old
• A child eligible to get services from the Children's Rehabilitative Services (CRS) program
• A pregnant woman
• Enrolled with American Indian Health Program (AIHP)
• Diagnosed as Seriously Mentally Ill (SMI) by the Arizona Department of Health Services (ADHS)
• An Acute Care AHCCCS member who is temporarily residing in a nursing home or residential facilities, if your medical condition would otherwise require hospitalization
• In hospice care, or
• Eligible for AHCCCS on a fee-for-service (FFS) basis.

To learn more about AHCCCS copayments, click here.

AHCCCS and Medicare Part D

If you are a senior or the Social Security Administration says you have a disability, you may be able to get AHCCCS and Medicare at the same time.

It will help you to have AHCCCS and Medicare Part D at the same time because:

• With AHCCCS, you will automatically be enrolled in a Part D benchmark plan and automatically qualify for the Part D Low Income Subsidy.
• The Low Income Subsidy means you may not have to pay a premium for your Part D or any deductibles.
• All you would pay for prescription drugs are Part D’s copayments, which range from $1.60 to $12.15.

To learn more, read DB101’s detailed information on the Part D Low Income Subsidy.

The AHCCCS Freedom to Work program lets Arizonans with a disability work and earn up to $6,606 per month. If you get AHCCCS Freedom to Work, you may have to pay a small monthly premium of $35 or less.

To qualify for AHCCCS Freedom to Work, you must be working and paying federal taxes, be between the ages of 16 – 64, and be certified disabled by the Social Security Administration. Read DB101’s article on AHCCCS Freedom to Work for detailed information on eligibility requirements and to find out how AHCCCS Freedom to Work interacts with other benefits programs.

AHCCCS Freedom to Work Prescription Benefits

With AHCCCS Freedom to Work benefits, you will only have to pay a small $2.30 copayment for most prescription drugs.

You do not need to make copayments if you are:

• Less than 19 years old
• A child eligible to get services from the Children's Rehabilitative Services (CRS) program
• A pregnant woman
• Enrolled with American Indian Health Program (AIHP)
• Diagnosed as Seriously Mentally Ill (SMI) by the Arizona Department of Health Services (ADHS)
• An Acute Care AHCCCS member who is temporarily residing in a nursing home or residential facilities, if your medical condition would otherwise require hospitalization, or
• In hospice care.

AHCCCS Freedom to Work and Medicare Part D

If you are eligible for both AHCCCS Freedom to Work and Medicare, you should sign up for both.

It will help you to have AHCCCS Freedom to Work and Medicare Part D at the same time because:

• With AHCCCS Freedom to Work, you will automatically qualify for the Part D Low Income Subsidy.
• The Low Income Subsidy means you may not have to pay a premium for your Part D or any deductibles.
• All you would pay for prescription drugs are Part D’s copayments, which range from $1.60 to $12.15.

To learn more, read DB101’s detailed information on the Part D Low Income Subsidy.

While you work, some of the money you earn automatically comes out of your paycheck and goes into a Medicare fund with other workers’ contributions. If you have to stop working because of a disability, Medicare will take money from this fund and use it to help you pay for your medical costs. Medicare is run by the federal government, though certain aspects of it are operated by private insurance companies, including its prescription drug coverage.

Like any insurance program, there are detailed rules about who can participate in Medicare and limits to what medical costs Medicare will help pay for. Medicare is very complicated because it is actually a set of programs, rather than just a single plan. Each program helps pay for a different aspect of your medical care. The programs are called “parts” and are named by letters. Medicare Part D is the program that helps pay for prescription drugs and is what we will focus on here.

To read a detailed description of all of the parts of Medicare, read the DB101 article on Medicare.

Part D Prescription Drug Coverage

Medicare Part D is also called Medicare Prescription Drug Coverage or MedicareRx. In the Part D program, private companies offer prescription drug coverage to people on Medicare. Each plan has a list of drugs that they will help pay for if you sign up with their plan. This list is called a formulary.

Part D coverage will not supply you with entirely free medications. Generally, you will be responsible for paying these expenses:

• A monthly premium. That means that you will have to pay a certain amount of money each month for your Part D plan, whether or not you purchase any medications.
• A deductible. That means that your Part D plan will not pay for any of your medications until you have spent a certain amount of money on medications yourself.
• Copayments or co-insurance. Copayments are a certain amount of money you have to spend each time you purchase a medication. Co-insurance means you have to spend a certain percent of a medication’s price out of pocket.

There is a $2,000 annual out-of-pocket maximum for Part D costs (not including premiums).

The premium, deductible, copayment, and co-insurance levels change each year on January 1. If you qualify for Medicare’s Low Income Subsidy, you may not have to pay all of these expenses. Persons who are enrolled in Part D and are enrolled in the Arizona Long Term Care System (ALTCS) have no cost-sharing for Part D covered drugs.

People who are on a Medicare Savings Program, Supplemental Security Income (SSI), or are eligible for both the Arizona Health Care Cost Containment System (AHCCCS) and Medicare have special rules for signing up, switching Part D plans, and paying for costs.

Getting Part D Coverage

There are 2 ways to get Part D drug coverage:

1. Enroll in a Stand Alone Prescription Drug Plan that only offers drug coverage. To enroll, you already have to be enrolled in Part A and/or Part B of Original Medicare or in a Medicare Advantage Plan that doesn’t offer drug coverage.
2. Through your Medicare Advantage Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee-For-Service Plan, or Special Needs Plan. Most of these plans offer prescription drug coverage as part of their larger package of Medicare benefits. Their drug benefits are called Medicare Advantage – Prescription Drug (MA-PD) plans.

You are not required to sign up for Medicare Part D if you have Medicare. Here are a couple of factors you should consider when you decide whether or not to sign up for Part D:

• If you have prescription drug coverage through your employer, union, retiree, or veterans (VA) coverage, those benefits may be better than Medicare Part D. If you have drug coverage from another source, compare your current policy with a Medicare Part D plan. One way to compare them is to ask your current drug insurance provider if your coverage is “creditable coverage.” Creditable coverage means that it is as good or better than Medicare Part D. Then, ask what happens if you sign up for Part D. Some insurance plans might not allow you to drop prescription coverage without also losing other benefits, and some plans might not let you get coverage back if you change your mind.
• If you don’t sign up for Medicare Part D during your initial enrollment period and change your mind later, there will be a penalty fee for signing up. It may be worth it to sign up for an inexpensive Medicare Part D plan so that you can avoid these penalties. If you currently have creditable coverage through another insurance plan, you can switch to Part D after the initial enrollment period without paying any penalties.

Choosing a Part D Plan

The best Part D Plan for you depends on the medications you need. To choose a Part D plan, make a list that includes the following information:

• All of the medications you are currently taking, including:
  • The dosage amount
  • How often you take them
  • If they are brand name or generic
• Ask your doctor about possible substitutes for the drugs you take
• The pharmacy where you prefer to get your medications and if you prefer mail order

Once you have this information, you can use it to compare your options online with Medicare’s Prescription Drug Plan Finder.

Drug manufacturers offer programs called Patient Assistance Programs (PAPs) that help low-income people get prescription drugs. Each PAP has its own rules about eligibility and what they will pay for. Before you look for a PAP, write down what drugs you need and make sure you have information about your income handy, such as your most recent paystub.

Here are a few ways to search for PAPs:

• Search using the Medicine Assistance Tool.
• Look at RxAssist’s database of Patient Assistance Programs, with up-to-date information on how to access assistance from nearly 100 companies and more than 700 medications.
• Go to Medicare.gov and check out its list of PAPs. This list is also useful for anybody, not just people on Medicare.

If you are enrolled in a health insurance or drug coverage program that already pays for your medications, you probably won’t be eligible for a Patient Assistance Program. However, insured individuals may be able to obtain a coupon directly from the drug manufacturer or from their doctor’s office that will help to reduce their prescription copayments.

People with HIV/AIDS need to take a lot of expensive prescription drugs. Some people have private or public health coverage that helps pay for their drugs, but some people don’t. And even those who do have health coverage may still have drug costs that their health coverage won’t pay for.

The AIDS Drug Assistance Program (ADAP) helps pay for HIV/AIDS drugs for people who have no insurance, private insurance, or Medicare Part D. It helps with medications that treat HIV and prevent the health of a person with HIV from seriously getting worse, including drugs that prevent and treat other infections you may get.

Eligibility

To get ADAP in Arizona, you must:

• Live in Arizona
• Be HIV positive
• Have income below 300% of Federal Poverty Guidelines
• Not be on the Arizona Health Care Cost Containment System (AHCCCS) or AHCCCS Freedom to Work

ADAP Drug Formulary

The ADAP Drug Formulary is the list of medications that ADAP pays for. Arizona’s formulary includes all primary HIV treatment drugs, opportunistic infection drugs, and many drugs for treating side effects. To see the entire list of medications in the Arizona ADAP Drug Formulary, click here.

How to Enroll

It is best to complete an application with the help of a Ryan White case manager. To read more about ADAP, click here.

For more information about Arizona HIV/AIDS resources, call Arizona ADAP at 1-800-334-1540.

Donald’s Story

Donald is a self-employed musician. He has been making a decent living for the last several years and because he was healthy, fit, and not even 30 years old, he only had a catastrophic health plan he got through HealthCare.gov.

He recently got tested for HIV and found out that he was HIV-positive. After that, he went to a doctor, who told Donald that he’d have to start taking a lot of prescription drugs.

Donald realized that because of his plan's high deductible, he wouldn't be able to afford all of the medications he'd need. And, even if he managed to pay that big deductible, his plan wouldn't pay for all of the medications he needed, because some of them were not on his plan's formulary — so he called up the Arizona AIDS Drug Assistance Program (ADAP) at 1-800-334-1540.

ADAP supplies HIV/AIDS-related prescription drugs to uninsured and underinsured people living with HIV/AIDS. Donald contacted an ADAP case manager, who helped him apply. He qualified for the program because he was HIV-positive, earned less than 300% of the Federal Poverty Guidelines ($3,913 a month), and was underinsured, meaning that his health insurance did not provide adequate coverage for the HIV/AIDS-related drugs Donald needed.