North Carolina AIDS Drug Assistance Program (ADAP)

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North CarolinaAIDS Drug Assistance Program
(ADAP)

• State Pharmaceutical Assistance Program (SPAP)

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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 dont count toward
  meeting TrOOP

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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

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Medicare Brief Review

• True-Out-Of-Pocket (TrOOP) Costs
• Individuals responsibility for their medications
  
• Deductible
• Percentage of the medication cost
• Copays
• Donut hole (coverage gap individual pays entire
  cost of the medication)

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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

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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

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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

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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

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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

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Benefits of SPAP

• ADAP pays only the clients 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 clients 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

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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

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Questions?

• Sally Kohls 919-733-9602 or sally.kohls_at_ncmail.n
  et
• Robert (Bob) Winstead 919-715-3115 or
  robert.winstead_at_ncmail.net
• NC ADAP Website http//www.epi.state.nc.us/epi/hi
  v/adap2.html