aids drug assistance program (adap) · 2018. 10. 4. · program (adap) treat & manage hiv....
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AIDS Drug Assistance Program(ADAP)
ADAP Branch
California’s Goal
Getting to Zero
AIDS Drug Assistance Program (ADAP)
Treat & Manage HIV
Pre-Exposure Prophylaxis (PrEP) Assistance
Program (PrEP-AP)Prevent HIV
Getting to Zero
•Zero new HIV Infections•Zero AIDS-related deaths
•Zero stigma & discrimination against people living with HIV
Laying a Foundation for Getting to Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan
Who Qualifies?
ADAPHIV+ individuals
PrEP-APHIV- individuals
at risk of infection
• CA residents
• Aged 18+
• Modified adjusted gross income = or <500% of the federal poverty level ( ~$60,700 or less for a household of 1)
• Not fully covered by another 3rd party payer (e.g. Medi-Cal)
What Does it Cover?
ADAP • Cost of prescription (Rx) drugs on the ADAP formulary• Health insurance premiums (if applicable)
Some medical out-of-pocket costs
PrEP-AP • Cost of Rx drugs on the PrEP-AP formulary• PrEP-related medical out-of-pocket costs
When using a provider in the PrEP-AP network
HIV+
HIV -
Big Picture: How Does it Work?
• Benefit managed by contractor Magellan Rx
• Over 4,000 CDPH-Magellannetwork pharmacies in CA
• Pharmacies dispense Rx’s on the ADAP and PrEP-AP formularies
Rx Benefits
• Benefit managed by contractor Pool Administrators Inc (PAI)
• PAI processes all medical out-of-pocket claims
• PAI processes all health insurance premium payments
Insurance Benefits
Small Picture: How Does it Work?
• Visit an ADAP / PrEP-AP enrollment site
• Enroll with a certified ADAP enrollment worker
Enroll
• ADAP –action required twice a year
Re-enroll annually Recertify every 6 months
thereafter• PrEP-AP –
action required once a year(with exceptions)
Re-enroll annually Uninsured clients & Medicare
clients with no Part D coverage re-enroll every 6 months
Maintain• Client gets a Magellan Rx ID Card Client fills prescription(s) at a
pharmacy within the CDPH-Magellan pharmacy network
• Client gets a PAI ID Card Only if ADAP is paying for client’s
health insurance premiums Client presents ID card at time of
service for medical out-of-pocket cost coverage (or sends PAI a completed paper claim form)
Use
Additional Programs
• No additional programs
ADAP • OA-HIPP
PrEP-APHIV -
HIV +
• EB-HIPP • MDPP
Additional Programs – Details
ADAP• OA-HIPP — Office of AIDS Health Insurance Premium Payment program• EB-HIPP — Employer-based Health Insurance Premium Payment program• MDPP — Medicare Part D Premium Payment program
HIV +
OA-HIPP Program Details
ADAP Office of AIDS Health Insurance Premium Payment (OA-HIPP) program
HIV +
OA-HIPP Coverage Private health insurance
premiumsPlan types:• Individual, Family• On and Off Exchange• COBRA, Cal-COBRA• Dental, Vision-combination plans
Outpatient medicalout-of-pocket costs
• That count toward policy’s annual out of pocket maximum
• Example: lab or office visit co-pays
Current coverage: up to $1938* a month in premiums per client
• Payments sent to health plan
HIV +
*Subject to reassessment and adjustment annually
EB-HIPP Program Details
ADAP Employer-based Health Insurance Premium Payment (EB-HIPP) program
HIV +
EB-HIPP Coverage Employer-based health
insurance premiumsPays for:• Employee’s portion of monthly
premium• Individual, Family plans• Dental, Vision-combination plans
Outpatient medicalout-of-pocket costs
• That count toward policy’s annual out of pocket maximum
• Example: lab or office visit co-pays
Current coverage:Up to $1,938* a month in premiums per client
• Payments sent to employer• Employer must agree to participate
HIV +
*Subject to reassessment and adjustment annually
MDPP Program Details
ADAP Medicare Part D Premium Payment (MDPP) program
HIV +
MDPP Coverage Medicare insurance
premiumsPays for:• Part D premiums• MediGap premiums
(if we are paying Part D)
Outpatient medicalout-of-pocket costs
• That count toward policy’s annual out of pocket maximum
• Example: lab or office visit co-pays
Current coverage:Up to $1,938* a month in premiums per client• Payments sent to health plan
HIV +
*Subject to reassessment and adjustment annually
PrEP-AP Program Details
• No additional programsPrEP-AP
HIV -
What is PrEP ?
• Pre-Exposure Prophylaxis (PrEP)• For HIV negative individuals• Reduces the chance of contracting HIV • Truvada® is the only medication approved by the FDA for use as an HIV PrEP• Gilead Sciences, Inc. manufactures Truvada® for PrEP• Gilead has 2 assistance programs that can help individuals pay for Truvada®
1) Gilead Co-Payment Assistance Program for the insured2) Gilead Patient Assistance Program for the uninsured
PrEP-AP Coverage
Out-of-pocket costs associated with getting PrEP
• Example: HIV testing, STI screening
• Must see a provider in the PrEP-AP provider network
Rx’s on the PrEP-AP Formulary
• Truvada®•Portion of Rx cost not covered by Gilead
• Other Rx’s used to treat or prevent sexually transmitted infections (STI’s)
• Rx’s are dispensed at CDPH-Magellannetwork pharmacies
HIV -
• Applicants enroll at an ADAP enrollment site that is certified to do PrEP-AP enrollment• Applicants must be co-enrolled in one of Gilead’s assistance programs (if eligible)• Covers:
Disclaimer
CDPH, Office of AIDS is charged with coordinating stateprograms, services, and activities relating to HIV/AIDS andoperates PrEP-AP in accordance with these duties. It is notaffiliated with, and does not endorse, nor is it endorsed byGilead Sciences, Inc., or its products.
Other ADAP Initiatives
•Enroll ADAP-only clients into health insurance•Achieve and maintain HIV viral load suppression among ADAP clients
HIV + HIV -
Access, Adherence and Navigation
•Enroll ADAP-only clients into health insurance•Achieve and maintain HIV viral load suppression among ADAP clients
Done via Access and Adherence Navigators
• Outreach to non-virally suppressed clients
• Outreach to ADAP-only clients (uninsured)
• Assess barriers• Refer for services• Accompany to
appointments• Provide Rx pick-up
reminders
• Enroll clients into health insurance, Medi-Cal, or Medicare, and ADAP insurance assistance program (as applicable)
1 2 3
HIV +
Goal
Getting to Zero
•Zero new HIV Infections•Zero AIDS-related deaths
•Zero stigma & discrimination against people living with HIV
Resources• ADAP and PrEP-AP General Information –
https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OAadap.aspx• ADAP Formulary –
https://cdph.magellanrx.com/provider/external/commercial/cdph/doc/en-us/CDPH_Formulary.pdf• PrEP-AP Formulary –
https://cdphprep-ap.magellanrx.com/member/external/commercial/caprep/doc/en-us/CDPH_PrEP-AP_Formulary.pdf• ADAP Enrollment Site Locator –
https://cdphdata.maps.arcgis.com/apps/webappviewer/index.html?id=e5a93c8e3f03424d8a414adf78c76e37• PrEP-AP Enrollment Site and Provider Locator –
https://cdphdata.maps.arcgis.com/apps/webappviewer/index.html?id=6878d3a1c9724418aebfea96878cd5b2• List of OA ADAP Advisors by County –
https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_adap_advisor_by_enroll_site.aspx• List of OA Insurance Assistance Program Advisors –
https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_adap_hipp_staffassignments.aspx• Laying a Foundation for Getting to Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan –
https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/IP_2016_Final.pdf• Contact Information –
PAi (insurance benefits manager) – (877) 495-0990 (Mon – Fri, 8 am – 5 pm)Magellan Rx (prescription benefits manager) – (800) 424-5906 (24/7)ADAP Call Center – (844) 421-7050 (Mon – Fri, 8am – 5 pm)
Questions or Comments ?