Britten Pund National Alliance of State & Territorial AIDS Directors July 5, 2011

1. The State of ADAPsReview of the 2011 National ADAP Monitoring Project Annual Report and Update on the ADAP Crisis Britten Pund National Alliance of State & Territorial AIDS Directors July 5, 2011

2. Presentation Agenda • Highlights from the 2011 National ADAP Monitoring Project Annual Report • Update on the ADAP Crisis • Questions and Answers

3. National Alliance of State & Territorial AIDS Directors (NASTAD) • Represents the nation’s chief health agency HIV/AIDS and viral hepatitis staff in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and the U.S. Pacific Islands • Provides technical assistance and other support to health department HIV/AIDS and viral hepatitis programs • Provides national leadership on HIV/AIDS and viral hepatitis policy and programs • Educates about and advocates for necessary federal funding

4. Highlights from the 2011 National ADAP Monitoring Project Annual Report

5. Methodology

6. Respondents • All ADAPs receiving federal ADAP earmark funding through the Ryan White Program were surveyed. • 57 jurisdictions were surveyed in September 2010; 52 responded. • 57 jurisdictions were surveyed in February 2011; 49 responded. • Non-responders represent <1% of estimated living HIV and AIDS cases in the United States.

7. Requested Data • Survey requests data and other program information for: • A one-month period (June 2010 or December 2010) • The current fiscal year (FY2010) • Other periods as specified • Data offers a monthly “snapshot” comparison from previous survey periods.

8. The Report

9. Module One • Detailed information related to : • ADAP budgets • Client enrollment and utilization • Client demographics • Program eligibility • Program management and administration

10. Module Two and Module Two Supplement • Detailed information related to: • Prescription distribution and payment methods • Expenditures and prescriptions filled • Insurance coordination • ADAP coordination with Medicare Part D • ADAP coordination with Pre-existing Condition Insurance Plans (PCIPs) • Updated client enrollment and utilization • Hepatitis treatments

11. Highlights from Module One

12. The National ADAP Budget • In FY2010, the national ADAP budget grew to $1.79 billion, a 13% increase from FY2009. • All funding streams increased incrementally over the last year.

13. The National ADAP Budget

14. The National ADAP Earmark

15. ADAP Emergency Funding • In August 2010, the Obama Administration reprogrammed $25 million to address ADAP waiting lists and other unmet ADAP needs. • Funding awards were made to 30 states. • Funding amounts ranged from $38,111 in Alaska to $6.9 million in Florida.

16. State Funding

17. Drug Rebates

18. Cost-recovery • “Cost-recovery” for medications purchased through ADAP (other than drug rebates) represented $50.5 million in FY2010. • Private insurance recovery represented 58% of all cost-recovery.

19. ADAP Expenditures, FY2009 • In FY2009, ADAPs expended $1.4 billion on prescription drugs, representing 85% of all ADAP expenditures. • ADAPs expended $176.1 million on insurance payments, representing 10% of all ADAP expenditures. • Two percent of ADAP funds were expended for program administration costs.

20. ADAP Client Enrollment and Utilization • On average, 2,806 new clients were enrolled in ADAP each month in FY2009.

21. ADAP Client Gender, Race/Ethnicity, and Age • Seventy-seven percent (77%) of ADAP clients are male. • Blacks and Hispanics comprise 55% (33% and 22% respectively) of ADAP clients served. • Almost half (48%) of ADAP clients are between the ages of 45 and 64. • Seventy-five percent (75%) of ADAP clients had income levels at or below 200% of the Federal Poverty Level (FPL).

22. ADAP Client Demographics

23. ADAP Client Insurance Status • Twenty-two percent (22%) of ADAP clients had private insurance. • Seven percent (7%) of ADAP clients were dual beneficiaries of both Medicaid and Medicare.

24. ADAP Eligibility Criteria • ADAP income eligibility in June 2010 ranged from 200% FPL in eight states to 500% FPL in six. • Fourteen ADAPs reported having asset limits in place in June 2010.

25. ADAP Management Policies • Thirty-three ADAPs have specific ADAP management policies in place, including: • Three ADAPs (6%) require client cost-sharing • Three ADAPs (6%) limit clients to a maximum number of prescriptions per client per month • Twelve ADAPs (24%) maintain a clinical criteria for client access to some medications on the ADAP formulary • Twenty-six ADAPs (51%) require prior authorization for clients access to some medications on the ADAP formulary

26. Highlights from Module Two

27. ADAP Client Utilization • ADAPs provided medications to 127,998 clients in December 2010. • Client utilization increased by 2% between June 2009 and December 2010; client utilization decreased by 2% between June 2010 and December 2010.

28. ADAP Drug Expenditures • ADAP drug expenditures were $146,457,975 in June 2010. • Ten states accounted for 76% of all drug spending; five states accounted for 57% of all drug spending.

29. Average Monthly Cost Per Client

30. ADAP Prescriptions Filled • In June 2010, the average expenditure per prescription was $325, compared to $302 in June 2009, representing an 8% increase. • Average expenditures per prescription was significantly higher for antiretrovirals ($491) than non-antiretrovirals ($67 for “A1” OIs and $64 for all other drugs). • ADAPs filled a total of 451,148 prescriptions in June 2010, representing an increase of 8% compared to June 2009.

31. ADAP Drug Expenditures and Prescriptions Filled (Including Drug Purchases and Co-Payments), by Drug Category, June 2010

32. ADAP Drug Expenditures and Prescriptions Filled (Including Drug Purchases and Co-Payments), June 2010

33. ADAP Insurance Coordination

34. ADAP Insurance Coordination • In June 2010, 110,338 ADAP clients were served through insurance coordination. • Clients served through insurance coordination more than tripled since June 2009. • Spending on insurance purchasing/continuation represented an estimated $139 per capita in June 2010, about 15% of the average monthly cost per client, based on drug expenditures, in that month ($949).

35. ADAP Coordination with Pre-existing Condition Insurance Plans • As of December 2010, 12 ADAPs reported having the ability to enroll clients in PCIPs. • Eleven states had 151 clients enrolled with plans to continue enrolling additional clients. • The average monthly cost per client served in a PCIP was $529 in December 2010, approximately 56% of the annual average cost per client, based on drug expenditures ($949) in that month.

36. ADAP Coordination with Medicare Part D • To meet the federal requirements and maintain appropriate medication coverage for their clients, 53 ADAPs have developed policies to coordinate with the Part D benefit.

37. ADAP Coordination with Medicare Part D • Twenty-six ADAPs reported signing a data sharing agreement with CMS in December 2010 (see Table 13). • Twenty-three ADAPs, including 9 who do not have a data sharing agreement with CMS, have a data sharing agreement with at least one other entity, including Medicaid, Medicare, private insurance providers, and other entities (e.g. Pharmacy Benefits Managers).

38. Highlights from Module Two Supplement

39. ADAP Coverage of Hepatitis B Treatment, December 2010

40. ADAP Coverage of Hepatitis C Treatment, December 2010

41. ADAP Coverage of Hepatitis A and B Vaccines, December 2010

42. Year in Review

43. The “Perfect Storm”

44. Patient Protection and Affordable Care Act • Patient Protection and Affordable Care Act (PPACA) signed into law in March 2010. • Some portions of reform that will impact ADAPs specifically are: • Medicaid eligibility expansion (2014); • Increase in the number of individuals covered by insurance plans (2014); • ADAPs’ Medicare Part D expenditures counting toward True Out Of Pocket (TrOOP) expenditures (2011); • Narrowing and closing of the Medicare Part D “doughnut hole (ongoing);” • An increase in the Medicaid rebate amount for purchased drugs; and (2010) • 340B pricing transparency.

45. Pharmaceutical Partners Contributions • In May 2010, pharmaceutical partners augmented current agreements with ADAPs including: • Providing deeper discounts; • Increased rebates; and/or • Price freezes to ADAP. • Pharmaceutical partners expanded the reach of Patient Assistance Programs (PAPs) and participated in Welvista for waiting list clients.

46. ADAP Waiting Lists • Over the course of 2010, 19 ADAPs reported a waiting list. • Several ADAPs decreased income eligibility requirements and disenrolled clients from ADAP in order to address shortfalls. • In FY2010, some ADAPs began transitioning clients off of ADAP and onto PAPs as a means of cost-containment. These clients were directed to seek access to medications through PAPs.

47. ADAP Waiting Lists and Cost-containment, as of May 2011

48. ADAP Waiting Lists, as of June 30, 2011 8,615 individuals in 13 states* Alabama: 73 individuals Arkansas: 40 individuals Florida: 3,562 individuals Georgia: 1,630 individuals Idaho: 20 individuals Louisiana: 824 individuals** Montana: 29 individuals North Carolina: 292 individuals Ohio: 485 individuals South Carolina: 810 individuals Utah: 25 individuals Virginia: 817 individuals Wyoming: 8 individuals *As a result of ADAP emergency funding, Hawaii, Idaho, Iowa, Kentucky, South Dakota, and Utah eliminated their waiting lists; Idaho reinstituted a waiting list in February 2011 and Utah reinstituted a waiting list in May 2011. **Louisiana has a capped enrollment on their program. This number represents their current unmet need.

49. ADAPs with Cost-containment, as of April 13, 2011 Arizona: reduced formulary Arkansas: reduced formulary, lowered financial eligibility to 200% FPL (disenrolled 99 clients in September 2009) Colorado: reduced formulary Florida: reduced formulary, transitioned 5,403 clients to Welvista from February 15, 2011 to March 31, 2011 Georgia: reduced formulary, implemented medical criteria, participating in the Alternative Method Demonstration Project (AMDP) Idaho: capped enrollment Illinois: reduced formulary, instituted monthly expenditure cap ($2,000 per client per month) Kentucky: reduced formulary Louisiana: discontinued reimbursement of laboratory assays North Carolina: reduced formulary

50. ADAPs with Cost-containment, as of April 13, 2011 (continued) North Dakota: capped enrollment, instituted annual expenditure cap, lowered financial eligibility to 300% FPL (grandfathered in current clients above 300%FPL) Ohio: reduced formulary, lowered financial eligibility to 300% FPL (disenrolled 257 clients in July 2010) Puerto Rico: reduced formulary South Carolina: lowered financial eligibility to 300% FPL (grandfathered in current clients above 300% FPL) Utah: reduced formulary, lowered financial eligibility to 250% FPL (disenrolled 89 clients in FY2010) Virginia: reduced formulary, transitioned 207 clients onto waiting list and PAPs, only distributing 30-day prescription refills Washington: instituted client cost sharing, reduced formulary (for uninsured clients only), only paying insurance premiums for clients currently on antiretrovirals Wyoming: reduced formulary, instituted client cost sharing