Virginia’s SPAP A Year of Success

1. Virginia’s SPAPA Year of Success Steven S. Bailey, LCSW Assistant Director, HIV Care Services Virginia Department of Health July 17, 2009 – Washington, D.C.

2. Background • Virginia’s SPAP provides ADAP eligible clients with Medicare Part D financial assistance with prescription drugs. • Medicare prescription legislation allows SPAPs to “wrap around” Medicare Part D benefit to fill gaps in coverage. • SPAPs must be considered “qualified” through CMS.

3. Eligibility • Set forth in state budget amendment • Virginia resident • Must be enrolled in ADAP • Must be enrolled in a Medicare Part D plan • Household income must be between 135% and 300% FPL.

4. Virginia Legislation • Budget Amendment: Chapter 3, Item 289 E, of the 2006 Acts of Assembly provides …… • Out of this appropriation, $300,000 the first year and $300,000 the second year shall be provided to establish a state pharmaceutical assistance program (SPAP) for insurance premium payments, co-insurance payments, and other out-of-pocket costs for individuals participating in the Virginia AIDS Drugs Assistance Program (ADAP) with incomes between 135 percent and 300 percent of the federal poverty income guidelines and who are Medicare Part D beneficiaries.

5. What is covered • Monthly Medicare Part D Premiums • Medication Deductibles • Medication Copays/Coinsurance • Medication Costs during Coverage Gap

6. Benefits of an SPAP • Clients may obtain policies with higher premiums, lowering medication copays • Costs incurred count toward TrOOP • Clients meet catastrophic coverage quicker • Fewer clients reliant on ADAP and other public funding • Clients receive assistance with ALL medications through their plan

7. Cost Savings(Projected, 2006-2007) • ADAP Cost per Client: $15,600/annually • Additional funds for non-ADAP medications • SPAP Cost per Client: $5,000/annually • $3,850 TrOOP (2006/07)+premiums+copays • Saving about $10,600/client/year • Example: 60 Clients • ADAP = $936,000/annually • SPAP = $300,000/annually

8. Cost Savings(Actual, 4/1/2008-4/30/09) • 4/08=52 Clients • By 4/09, increased to 125 Clients • By 9/08, cost-sharing assistance more fully utilized • n=54 Clients (using only the ADAP formulary) • Cost Avoidance of $94,370.34

9. Cost Savings(Actual, 4/1/2008-4/30/09) • n=80 Clients (accessing all medications) • Average monthly ADAP cost = $1,300 • Average monthly SPAP copay = $383.95 • Cost Savings • $916.05/client/month • $879,408 annually for 80 clients • Note: Not all client utilized the SPAP for all medications

10. Challenges to the State • Legislature (Virginia General Assembly) • Funding • Language of the Law • Federal Match • Agency infrastructure/technology Strategies • Stakeholders, Community Partners • Support of Business Staff • Contract Out (PSI)

11. Challenges to the Vendor • Staff Time with Clients • Relationship Development with Clients • Data management and exchange • Strategies • Investing up front • IT Support

12. Challenges with Pharmacies • Client Choice • Pharmacy trust • Method of payment • Strategies • Outreach • Electronic Billing Options

13. Challenges with Providers • Apprehension • Change in Medication Access Mechanism • Dissuaded Clients from Enrolling Strategies • Statewide Education Methods • Communication with Key Contacts

14. Challenges to Clients • Trust • Fears of Decreased Access • Education • Last Minute Refills Strategies • Consortia and Client Groups • Education Strategies • Direct Client Contact

15. Questions and Comments Steven S. Bailey, LCSW Assistant Director, HIV Care Services (804) 864-8065 Steve.Bailey@vdh.virginia.gov Patient Services Incorporated (PSI) (800) 366-7741