Prescription Drug Coverage

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.

You are HIV positive and have no insurance. When you try to enroll in ADAP, they tell you that you first have to apply for Medi-Cal. You are denied Medi-Cal coverage. ADAP will pay for the entire cost of your HIV medications.

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.

You are enrolled in ADAP and also have private health coverage. Your doctor prescribes two medications, Viramune and Combivir. Viramune isn’t covered by your private coverage, and Combivir requires that you pay 20% of the cost. ADAP will pay for the entire cost of the Viramune and will pay the 20% co-insurance for the Combivir.

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) ($72,900 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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