Prescription Drug Coverage
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The Basics
Many conditions are treated with drugs that your doctor prescribes. These drugs can be necessary for you to stay healthy. They can also be expensive. There are a number of ways that you can get help paying for prescription drugs. If you have private or public health coverage, it may cover prescription drugs. If you don’t have coverage, or the coverage doesn’t pay for all of your costs, there are programs that may be able to assist you. The AIDS Drug Assistance Program (ADAP) helps those with HIV/AIDS, and drug companies also have Patient Assistance Programs (PAPs) for people who meet certain requirements. Medi-Cal and Medicare both have prescription drug coverage but may require you to pay a premium, deductible, copayment, or co-insurance.
Most of the programs that offer prescription drug coverage are described in detail elsewhere on DB101. In this section, you’ll find brief descriptions of these programs, along with information on Patient Assistance Programs (PAPs), and a detailed program description of the AIDS Drug Assistance Program (ADAP).
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Private Health Coverage
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.
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Medi-Cal
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Medi-Cal
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.
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Medicare
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. 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.
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Medi-Cal covers people with and without disabilities who have low income.
Prescription Drug Coverage
- The Basics
- Private Health Coverage
- Medi-Cal
- Medicare
- Patient Assistance Programs
- AIDS Drug Assistance Program
- Example
- FAQs
- Pitfalls
- Resources
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Patient Assistance Programs (PAPs)
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.
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Programs
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Medi-Cal
Medi-Cal covers people with and without disabilities who have low income.
Prescription Drug Coverage
- The Basics
- Private Health Coverage
- Medi-Cal
- Medicare
- Patient Assistance Programs
- AIDS Drug Assistance Program
- Example
- FAQs
- Pitfalls
- Resources
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AIDS Drug Assistance Program (ADAP)
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) ($67,950 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.
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Example
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.
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Frequently Asked Questions
What is the AIDS Drug Assistance Program (ADAP)?

If you qualify, ADAP may pay for some or all of the cost of HIV/AIDS related medications that other insurance does not cover.
Is ADAP the same in all states and Commonwealths?

No. Although ADAP is available in all 50 states and Commonwealths, it is not the same everywhere. Each state or Commonwealth is responsible for:
- Establishing ADAP eligibility;
- Determining the type, amount, duration and scope of services;
- Developing a list of covered prescriptions on its formulary; and
- Administering the Program.
Who is eligible for ADAP?

To be eligible for ADAP you must:
- Be a California resident;
- Be at least 18 years of age;
- Have an HIV/AIDS diagnosis;
- Have a valid prescription from a California licensed physician;
- Have a Federal Adjusted Gross Income that does not exceed $50,000; and
- Have limited prescription drug coverage.
What does ADAP provide and how long will it last?

ADAP covers some or all of the cost associated with medications commonly used to treat HIV/AIDS and related complications. ADAP benefits will last as long as you meet the eligibility and annual recertification requirements.
What are the medical eligibility requirements for ADAP?

You must have an HIV or AIDS diagnosis.
Does what I have in the bank and/or what I own, such as a home or car, affect my eligibility for ADAP?

No. What you have in the bank and what you own does not affect your ADAP eligibility. ADAP uses your Federal Adjusted Gross Income to determine financial eligibility. This income must be under $50,000 per year.
How do I prepare to apply for this benefit?

You will need the following documents to complete your ADAP application:
- Proof of California residence (e.g. rental agreement or utility bill).
- Picture identification (California Driver's License, California Identification card, Passport, School I.D., etc.)
- Proof of income (Federal or State Income Tax returns with corresponding W2 or 1099 forms, pay stubs, Public Assistance or Social Security Award Letters).
- Proof of Medi-Cal application (if applicable) and/or documentation of any current health coverage (if applicable).
- Letter of HIV diagnosis including CD4 count and viral load from a physician.
How do I apply for ADAP?

To apply for the AIDS Drug Assistance Program, contact the local ADAP coordinator in your county to find the nearest enrollment in your area.
What other benefit programs are available to me and how do they work with ADAP?

In general, ADAP is the payer of last resort. If you are eligible for private health coverage with prescription benefits, ADAP will require you to use those benefits first before paying any copayments, coinsurance, or deductibles. ADAP can also pay for drugs that aren't covered under the insurance plan.
If you are considered to be potentially eligible for Medi-Cal, ADAP will require you to apply for such coverage. If you are eligible for free Medi-Cal, you cannot get ADAP. If you are eligible for Medically Needy Medi-Cal with a Share of Cost, costs that ADAP covers can go towards your share of cost. If you are eligible for other types of Medi-Cal, Medi-Cal will pay first and ADAP second.
If you have Medicare the California Office of AIDS has information about how the programs interact.
How do I stay enrolled/eligible in ADAP? How often do I have to reapply?

To be eligible for ADAP you must continue to meet the financial eligibility requirements for the program. In addition, ADAP requires you to recertify annually.
What happens when I work while receiving benefits from ADAP?

If you continue to meet the financial eligibility requirements for ADAP and recertify annually, working will not affect your benefits from this program.
If your income increases above 400% of the Federal Poverty level, but stays below $50,000, you will continue to be eligible for ADAP but will have a copayment.
What happens if I don't have all of the required documentation when I apply for ADAP?

If you do not have all the required documentation for your ADAP application, you may qualify for temporary (30-day) access to prescription benefits. However, you must submit any missing documentation within 30 days of the application date to continue receiving benefits.
Can I use ADAP to meet my Medi-Cal share-of-cost?

It depends. If you have Medi-Cal without Medicare, drugs that ADAP pays for can help meet your share of cost. If you have Medi-Cal and do have Medicare, ADAP will not meet your share-of-cost.
Will ADAP pay my County Medi-Cal Services Program (CMSP) share-of-cost?

No. ADAP will only cover your County Medi-Cal Services Program for prescriptions on the ADAP formulary.
What is the Pharmaceutical Research and Manufacturers of America (PhRMA)?

PhRMA represents American drug and biotechnology companies. Their Medicine Assistance Tool (MAT) is a search engine for Patient Assistance Programs (PAPs) and the prescriptions that are covered. PAPs help uninsured and underinsured individuals get free or discounted prescription drugs.
What are Patient Assistance Programs (PAPs)?

Drug companies offer Patient Assistance Programs (PAPs) to provide free or discounted prescription drug coverage to uninsured and underinsured people. These include Medicare and Medi-Cal beneficiaries and those who have private health insurance but lack adequate prescription drug coverage.
Are PAPs the same in all states?

PAPs are neither federal nor state-run programs. They provide prescription drug assistance to individuals who qualify through pharmaceutical companies.
Who is eligible to participate in PAPs?

For the most part, Patient Assistant Programs (PAPs) serve people who are either uninsured or underinsured. Some PAPs offer assistance to Medicare and Medi-Cal beneficiaries. Eligibility requirements for individual PAPs vary widely, so be sure to check each program before applying.
What do PAPs provide and how long will it last?

Benefits for PAPs are not standardized. Some offer free or discounted prescription drugs for 3 months, while others offer benefits for 6 months. Many require an annual reassessment. Every program is different, so you should check with each PAP for an explanation of benefits.
Are there any medical eligibility requirements for PAPs?

Depending upon the PAP, medical eligibility requirements may require you to have a specific diagnosis. Many PAPs, however, do not. Be sure to check with each PAP for specific medical eligibility requirements.
Does what I have in the bank and/or what I own, such as a home or car, affect my eligibility for PAPs?

Sometimes. Many PAPs have financial eligibility requirements, while others do not. Because there are no standard financial eligibility requirements among PAPs, you should check with each program for financial requirements.
How do I prepare to apply for a PAP?

Before applying for a PAP, you should gather the following information:
- Age;
- State of residence;
- Estimated gross annual household income;
- Name of prescription drugs; and
- Type of health insurance and/or prescription coverage (if applicable).
How do I find a PAP that meets my needs?

PhRMA’s Medicine Assistance Tool (MAT) is a search engine for Patient Assistance Programs (PAPs) and the prescriptions that are covered. DB101's Prescription Drug Coverage Resources section lists other websites that have PAP finders.
How soon after applying will I be eligible for benefits from a PAP?

Each PAP has its own timeline for making prescription drug assistance available. Some programs deliver prescription drugs within 3-4 weeks, while others may take several months. It is best to check with each PAP to see when benefits will become available.
How do I stay enrolled in a PAP? How often do I have to reapply?

To stay enrolled, you need to follow the requirements of that particular program. Many programs require you to reapply each time you need a prescription, while others require an annual application. Because PAPs are not standardized, you should check with the program for specific requirements.
Are there rules for immigrants to qualify for a PAP?

Many PAPs require you to be either a U.S. resident or citizen. However, not all PAPs have residency requirements. It is best to check with each PAP for specific residency requirements.
What happens when I work while receiving benefits from a PAP?

Most PAPs have requirements that are based upon insurance status. Unless a PAP has income requirements, working should have no effect on your eligibility for a program.
What else should I be aware of?

Each PAP is different. You should check with each PAP in which you wish to participate for specific information on eligibility requirements and application procedures.
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Common Pitfalls
Losing eligibility for a Patient Assistance Program (PAP)
Many programs require you to reapply each time you need a prescription, while others require an annual application. You should check with each Patient Assistance Program for specific requirements. To stay enrolled in a PAP, you need to understand and follow the requirements of that particular program.
Confusing eligibility between Patient Assistance Programs
Each Patient Assistance Program (PAP) is different. You should check with each PAP you wish to participate in for specific information on eligibility requirements and application procedures.
Not considering Patient Assistance Programs
Many individuals are not aware of Patient Assistance Programs because they may have other coverage, such as private health coverage, Medi-Cal or Medicare Part D. In some instances, you may be able use a PAP when your current coverage does not cover a particular medication(s).
Failing to accept employer-sponsored health coverage
Sometimes an individual is enrolled in a health insurance plan that does not include prescription coverage. Under these circumstances, you may want to apply for the AIDS Drug Assistance Program (ADAP). While this is a great benefit, you will only be covered for drugs related to HIV/AIDS treatment. If you have the opportunity to enroll in employer-sponsored health coverage, then you may be able to receive full prescription coverage for all conditions. Also, the ADAP program has income limits that are not present in private health coverage offered through an employer.
Not applying for ADAP because you are not eligible for Medi-Cal
If you are enrolled in Medi-Cal, you can be eligible for the AIDS Drug Assistance Program (ADAP). If you are not eligible for Medi-Cal, you can still be eligible for ADAP if you meet the Program's requirements.
Not knowing when to use ADAP to cover a share of cost
Many individuals use the AIDS Drug Assistance Program to cover a Medi-Cal share of cost. This involves the pharmacy billing ADAP for the individuals' share of cost as they fill or refill prescriptions. This process allows them to be able to access Medi-Cal without incurring any expenses. The best way to do this is at the beginning of the month so that you will have Medi-Cal available to you for the rest of the month at no cost.
Not knowing about all of your prescription options
ADAP may not be the most cost-effective approach for prescription drugs. You should consider all of your options before making a decision to use ADAP.
Other options that may be available to you include:
In some cases large retailers with pharmacies may offer the best price.
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Resources
Prescription Drug Discount Programs
NeedyMeds, Inc. provides information about Patient Assistance Programs (PAPs) to individuals, healthcare professionals, patient advocates, social service workers and others. NeedyMeds, Inc. also assists with completing applications for PAPs.
PhRMA’s Medicine Assistance Tool (MAT) is a search engine for Patient Assistance Programs (PAPs) and the prescriptions that are covered.
RxAssist has a database of Patient Assistance Programs, with up-to-date information on how to access assistance from nearly 100 companies and more than 700 medications.
The AIDS Drug Assistance Program (ADAP) provides prescription coverage for HIV related medication. ADAP can cover some or all of the cost of prescription drugs. Call the ADAP coordinator in your county to find the enrollment site in your area.
HIV/AIDS Resources
AIDS Project Los Angeles is an excellent resource for information on Services and how they relate to HIV/AIDS.
The AIDS Hotline of California has information on approximately 1,200 organizations that serve people with HIV/AIDS and STDs. The hotline's toll free number is 1-800-367-2437.
HIV LA provides a comprehensive resource directory of service providers for persons living with HIV in Los Angeles County. Listings are categorized by geographic region.
The Journal of the American Medicine Association (JAMA) is an international peer-reviewed medical journal. JAMA has an HIV section that publishes current research, news, prevention facts, updates, references, guidelines, treatment reviews and drug information.
Project Inform is an advocacy organization that provides information on treatment for people living with HIV/AIDS, caregivers, healthcare and service providers. Project Inform advocates for regulatory policies, legislation, funding for HIV research, treatment and an AIDS cure. This website contains information on treatment, women's issues, education and a national hotline.
The California Office of AIDS is responsible for coordinating state programs, services, and activities relating to HIV/AIDS. The Office of AIDS has three Branches:
- HIV/AIDS Epidemiology;
- HIV Education and Prevention Services; and
- HIV Care.
This website contains reports, education and prevention information and an Office of AIDS Directory.
Getting Help with Your Benefits
If you get Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or Childhood Disability Benefits (CDB), and you're looking for a job, a trained Benefits Planner can help you avoid problems with your job plan. If you need help or have questions about your situation, you can call the Ticket to Work Help Line at 1-866-968-7842 or 1-866-833-2967 (TTY), Monday through Friday.
View DB101's full list of experts who can help you understand different benefits.
Community-Based Organizations
Various community-based organizations guide people through state, federal, public, and private health and income programs. Some organizations may work with specific populations while others work with people with any type of disability. Here are a few examples
Goodwill Industries services range from personal evaluation and office skills training to career counseling, childcare, and transportation. Some Goodwill Industries centers also do benefits planning for people who get SSI, SSDI, and Medicare. Find locations at www.Goodwill.org, or by calling (voice) 1-800-466-3945.
The California Foundation for Independent Living Centers lists centers serving people with all disabilities. Many of these centers do benefits planning for people who get SSI, SSDI, and Medicare. If they don't offer benefits planning themselves, Independent Living Centers can refer you to local benefits planners. Find the list of independent living centers at www.CFILC.org, or by calling (voice) 1-916-325-1690 or (TTY) 1-916-325-1695.
The California Department of Public Health's Office of AIDS lists 1,300 organizations offering HIV/AIDS services throughout California. Some of these organizations provide case management, benefits planning, and benefits counseling services that can include help with public and private benefits programs. You can search the list online, or call (voice) 1-800-367-AIDS (2437) or (TTY) 1-888-225-AIDS (2437).
Disability Rights California provides representation for consumers of public programs who are disabled. Website publications include topics on health care, benefit programs, and In-Home Supportive Services.
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Medi-Cal
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