Most Private Health Coverage plans have some sort of prescription drug coverage. You or your employer pay a monthly premium to be enrolled in a plan. When you get medical services, the plan will help you pay for the costs of those services that it has agreed to cover. Depending on the specifics of your plan, prescription drugs may be one of those services. You may have to pay a certain amount of money before your plan will help you pay. This is known as a deductible. After you’ve paid your deductible, you may have to pay each time you buy drugs. You may pay a small fee, called a copayment, for every prescription you buy. Other plans may require that you pay a certain percentage, called co-insurance, of the cost of each drug. Every plan will be different. Some may not cover prescription drugs at all. Check the specifics of your plan to see what is covered under which circumstances. DB101’s Private Health Coverage section has more information on enrollment, rules, and other general information on Private Health Coverage.

Medi-Cal is a program that offers health coverage to people with low income who are over 65, blind, or disabled. Medi-Cal is California’s Medicaid program. It usually comes with extensive prescription drug coverage. Depending on your situation, this coverage can be free, cost a small premium, or require that you spend a certain amount of your own money before coverage begins. DB101’s section on Medi-Cal has detailed information on common ways to enroll in the program, along with information about how the benefit works.

In 2003, Medicare added prescription drug coverage. It previously only offered hospital (Part A) and outpatient (Part B) coverage. The new prescription drug benefit is called Medicare Part D. Private companies manage Part D prescription drug plans while the government determines eligibility and enforces program rules. You generally have to pay premiums, deductibles, and copayments or co-insurance, but there is help available for many of those who can’t afford these costs and there is a $2,000 annual out-of-pocket maximum for Part D costs (not including premiums). There are also special rules about people who are eligible for both Medi-Cal and Medicare. DB101’s Medicare section has more information on Part D.

Private drug companies offer programs that help low income people afford prescription drugs. Each PAP has its own rules about eligibility and what they will pay for. Many of these companies are part of a group called PhRMA, whose Medicine Assistance Tool (MAT) lets you search for Patient Assistance Programs (PAPs) and the prescriptions that are covered. You will have to have information about your income and drug needs in order to find a PAP that meets your needs. The DB101 resources section on PAPs also lists other websites that have guides to PAPs. For more information on PAPs, go to one of those websites or see this article's Frequently Asked Questions.

People with HIV/AIDS generally need to take a lot of prescription drugs. Many of these drugs are expensive. Some people get help paying for them through private or public health coverage programs. But some people aren’t on those programs and even those who are sometimes still have drug costs beyond what their health coverage will pay for. There’s a program called the AIDS Drug Assistance Program (ADAP) that helps people with HIV/AIDS pay for the costs of some prescription drugs.

How ADAP Works

ADAP is what is called a payer of last resort. That means that you have to apply for all other programs that might help pay drug costs and use those programs before ADAP will help pay.

If you are on other insurance, ADAP can help pay for drugs that aren’t covered by that plan, or for the portion of the cost that you would normally have to pay out of pocket. You may, for example, have to pay a deductible, which is a certain amount of money you have to pay before insurance will start helping with your costs. You also may have to pay a small fee, called a copayment, for each drug you buy, or a certain percentage, called co-insurance, of the cost of the drug.

ADAP only covers drugs for HIV/AIDS and related conditions. There’s a list of drugs that ADAP will help pay for. This list, like similar lists from other health coverage programs, is called a formulary. ADAP’s formulary has more than 150 drugs on it. To get ADAP to help pay for drugs, you have to go to one of the 5,500 participating pharmacies in California.

Eligibility and Enrollment

ADAP is coordinated by the Office of AIDS in the California Department of Public Health. They have a webpage on ADAP that has basic information about the program, the current formulary, participating pharmacies, and enrollment sites. To be eligible for ADAP, you have to meet all of the following requirements:

• Be HIV positive
• Be a California resident
• Be 18 or older
• Have income at or below 500% of the Federal Poverty Level (FPL) ($75,300 per year for an individual)
• Have a prescription from a California doctor
• Have limited or no prescription drug coverage, and
• Not qualify for no-cost Medi-Cal.

To enroll in ADAP, you have to go to one of the 250 enrollment sites in California. To find an enrollment site in your area, call the local ADAP coordinator in your county.

You’ll need to bring the following documents with you when you enroll:

• Proof of residence (like a utility bill)
• Photo ID
• Verification of Income (like tax returns, pay stubs, or benefit award letters)
• Applications to Medi-Cal or private health coverage, and
• A letter of HIV diagnosis from within the past 6 months.

Interaction with Medicare and Medi-Cal

If you are on Medicare Part D and ADAP, ADAP is still the payer of last resort. To stay eligible for ADAP, you must enroll in Medicare Part D if you are eligible. You should make sure you go to a pharmacy that participates in your Part D plan as well as ADAP. In general, Part D plans will pay for most of your HIV/AIDS drugs. This is because antiretrovirals are one of the categories of drugs that Part D plans must cover fully. You have to apply for Part D’s Low Income Subsidy before ADAP will pay. ADAP pays for copayments, deductibles, co-insurance, and may cover other prescription drug costs. If you have both Part D and ADAP, you can also apply to have your Part D premium paid for.

If you are on Medically Needy Medi-Cal with a Share of Cost (SOC), that means that you have to spend a certain amount of money each month before Medi-Cal starts to pay. The money spent on drugs that are paid for through ADAP can count towards your SOC. If you’re on Medi-Cal and Medicare Part D, it will be difficult to spend down your SOC because the only drugs that aren’t covered by either Part D or Medi-Cal are Xanax and Atavan.

Anna's Story

Anna recently found out that she had HIV. After meeting with her doctor and hearing about all of the treatment options available, she realized that she was going to be taking a lot of prescription drugs. She had private health coverage through her job in Los Angeles, but she wasn’t sure how much that insurance plan would pay for. Anna did not feel comfortable telling her human resources department that she was HIV positive, so she simply asked for a copy of the policy. When she got home and started reading through it, she understood the basics of the policy, but wanted some help with the details. She decided to call a local organization that had expertise dealing with HIV/AIDS and benefits. She made an appointment to speak with one of their benefits planners, Alfonso. On the phone, he told her to bring a copy of the insurance policy.

At Alfonso’s office, Anna explained that she was most worried about how she would pay for her prescription drugs. Alfonso took a few minutes to carefully read through her policy. After he finished, he explained what he thought.

Alfonso said, “Most of the common HIV/AIDS drugs are covered by your plan. Your plan, however, has a $500 deductible and 20% co-insurance.”

When he noticed that Anna was beginning to look a bit confused, he explained that a deductible is a certain amount of money that you have to pay before insurance kicks in. “For example, let’s say that you get a prescription that costs $50 and is covered by your plan,” Alfonso said. “You’ll have to pay for the entire cost of that drug because you haven’t met your deductible yet. Once you’ve spent $500, the insurance will kick in.”

Anna asked, “And then they’ll pay for the entire cost of the drug?”

“No,” Alfonso replied, “that’s when the co-insurance starts. Your insurance company will pay for 80% of the cost of the drug, and you’ll have to pay the other 20%. There may, however, be help available for you to pay those costs. If you have less than $50,000 in Federal Adjusted Gross Income each year and meet other rules, you might be eligible for a program called the AIDS Drug Assistance Program (ADAP). It can pay for some or all of the costs for HIV/AIDS drugs, depending on how much income you have. You can find out how much your Federal Adjusted Gross Income is by looking at your tax returns.”

Anna laughed and said, “Well, I don’t know exactly what my tax returns say, but I’m positive it’s less than $50,000. How do I sign up?” Alfonso told her that the Office of AIDS coordinates the program in California. He explained that she could sign up at one of the approximately 250 enrollment sites in California. "You can call the local ADAP coordinator in your county to find an enrollment site in your area," Alfonso said.

Anna enrolled in ADAP and was able to have them pay the entire cost of her deductibles and co-insurance.