The 64-year-old man was losing weight at a dangerous rate, a consequence of his HIV, a diagnosis he received in 1992. He was often overwhelmed with malaise. Fatigue was a constant companion.
“It affected every area of his life,” said Adrian M. Lowe, a staff attorney at the AIDS Law Project.
His doctor hoped a liquid nutritional supplement would remedy the decline and wrote him a prescription for three cans a day. He took the prescription to the specialty pharmacy he used, assuming his insurance would cover it. He had Medicare and Medicaid. He had Medicare because of his work history, and Medicaid through the Medical Assistance for Worker’s with a Disability (MAWD) because he had a small part-time job. Then he got the bad news. His insurance refused to pay for it. His only income was Social Security Disability Insurance. There was no way he could pay for the supplement on his own.
“He was discouraged,” Adrian said. “He had thought it would be covered.”
After the man came to the AIDS Law Project in December 2015, Adrian set about figuring out what to do. He learned that Medicaid does in fact cover nutritional supplements, but requires prior authorization, which the client had not obtained. The medical need must be documented to obtain prior authorization, so Adrian worked with his client’s doctor and nutritionist to assemble all the necessary medical records, a lengthy process. Adrian was finally able to apply for prior authorization in May and in July the state Office of Medical Assistance Programs approved it.
“He was grateful that he finally got what his doctor had prescribed.” Adrian said. “No one should have to wait that long to get something as basic as nutritional supplements.”