North Carolina AIDS Drug Assistance Program (ADAP)

1. North CarolinaAIDS Drug Assistance Program (ADAP) State Pharmaceutical Assistance Program (SPAP)

2. What is an SPAP • State Pharmaceutical Assistance Program (SPAP) • Special designation by CMS • Data sharing between ADAP and CMS • Medicare eligible clients on ADAP identified • Low Income Subsidy (LIS) status identified • Federal Poverty Level identified • State funds used to pay cost sharing • RW (federal) funds currently don’t count toward meeting TrOOP

3. Medicare Part D – Brief Overview • Medicare Prescription Drug Benefit • Started in 2006 • Provides prescription drug coverage for anyone Medicare eligible • Individual signs up for a PDP • May be eligible for LIS through Social Security – separate application • All HIV drugs (ARVs) covered (CMS requirement) • Premiums vary, deductibles vary ($0 - $295) • Cost sharing varies (copays, coninsurance, donut hole) – called TrOOP

4. Medicare – Brief Review • True-Out-Of-Pocket (TrOOP) Costs • Individual’s responsibility for their medications • Deductible • Percentage of the medication cost • Copays • Donut hole (coverage gap – individual pays entire cost of the medication)

5. Medicare – Brief Review • The Donut Hole – What is it? • Individual pays the entire cost of medications • How does an individual get into the donut hole? • The total medication cost is used to move the person into the donut hole – what the drug plan pays and what the person pays (copay/coninsurance) • To get into the donut hole = $2700 total drug costs • To get out of the donut hole = $4350 completely paid by the person

6. Why An SPAP? • In 2006 – ADAP was approved to continue covering the Medicare eligible clients even though clients had prescription drug coverage – Why? • May have resulted in medication gaps since donut hole is unaffordable for most • Clients would have been worse off with the new PDP – coverage level much less • Potential for increased transmission of HIV if viral load is not maintained at a low or undetectable level

7. Why An SPAP? • As an ADAP • Cannot use Ryan White (federal) funds to coordinate with Medicare Part D • Provided medication regimen at the full cost to ADAP • Medication costs not coordinated with or reported to Medicare • As an SPAP – • State funds used to pay the TrOOP on behalf of the client for all drugs on the ADAP formulary • Copays, coinsurance, donut hole paid for by ADAP • Costs reported to Medicare TrOOP facilitator • No cost to client for drugs on the ADAP formulary

8. What is Required for Medicare Eligible Clients on NC ADAP • Must meet NC ADAP eligibility criteria • Must sign up for a Medicare Part D PDP or Advantage Plan with Prescription Drug Coverage • Client pays premium – averages $30/month • Client pays copay or co-insurance for non-ADAP formulary drugs • If below 150% of the federal poverty level must sign up for the low income subsidy (LIS) through Social Security

9. NC SPAP Process • Same central pharmacy used for both ADAP and SPAP clients • Original pharmacy contract required that Medicare and Medicaid eligibility are checked at time of medication dispense • If Medicare eligible – dispense processed through the PBM • TrOOP facilitator updated real-time • Billing separate – only state funds used for clients on SPAP • Dispensing reports separate

10. Benefits of SPAP • ADAP pays only the client’s TrOOP for drugs on the NC ADAP formulary (copays/coninsurance/donut hole) • All costs paid on behalf of client are reported to the Medicare TrOOP facilitator • Helps move client into catastrophic coverage level • Saves a significant proportion of the costs previously expended for the client’s regimen as a regular ADAP client • Helps ensure open enrollment into ADAP • Allows for additional services, such as adherence counseling • Allows for an expanded formulary

11. Challenges • NC ADAP information about Medicare eligible clients was incomplete • Educating Case Managers about Medicare Part D and the SPAP • Enrollment not during normal open enrollment period • Contacting Clients • Ensuring enrollment into Part D • Resistance from clients and case managers • Non-ADAP Medication Costs • CMS Data Files • Medications not on Medicare PDP formulary

12. Questions? • Sally Kohls: 919-733-9602 or sally.kohls@ncmail.net • Robert (Bob) Winstead: 919-715-3115 or robert.winstead@ncmail.net • NC ADAP Website http://www.epi.state.nc.us/epi/hiv/adap2.html