AIDS Drug Assistance Program(ADAP)

ADAP Branch

California’s Goal

Getting to Zero

AIDS Drug Assistance Program (ADAP)

Treat & Manage HIV

Pre-Exposure Prophylaxis (PrEP) Assistance

Program (PrEP-AP)Prevent HIV

Getting to Zero

•Zero new HIV Infections•Zero AIDS-related deaths

•Zero stigma & discrimination against people living with HIV

Laying a Foundation for Getting to Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan

Who Qualifies?

ADAPHIV+ individuals

PrEP-APHIV- individuals

at risk of infection

• CA residents

• Aged 18+

• Modified adjusted gross income = or <500% of the federal poverty level ( ~$60,700 or less for a household of 1)

• Not fully covered by another 3rd party payer (e.g. Medi-Cal)

What Does it Cover?

ADAP • Cost of prescription (Rx) drugs on the ADAP formulary• Health insurance premiums (if applicable)

Some medical out-of-pocket costs

PrEP-AP • Cost of Rx drugs on the PrEP-AP formulary• PrEP-related medical out-of-pocket costs

When using a provider in the PrEP-AP network

HIV+

HIV -

Big Picture: How Does it Work?

• Benefit managed by contractor Magellan Rx

• Over 4,000 CDPH-Magellannetwork pharmacies in CA

• Pharmacies dispense Rx’s on the ADAP and PrEP-AP formularies

Rx Benefits

• Benefit managed by contractor Pool Administrators Inc (PAI)

• PAI processes all medical out-of-pocket claims

• PAI processes all health insurance premium payments

Insurance Benefits

Small Picture: How Does it Work?

• Visit an ADAP / PrEP-AP enrollment site

• Enroll with a certified ADAP enrollment worker

Enroll

• ADAP –action required twice a year

Re-enroll annually Recertify every 6 months

thereafter• PrEP-AP –

action required once a year(with exceptions)

Re-enroll annually Uninsured clients & Medicare

clients with no Part D coverage re-enroll every 6 months

Maintain• Client gets a Magellan Rx ID Card Client fills prescription(s) at a

pharmacy within the CDPH-Magellan pharmacy network

• Client gets a PAI ID Card Only if ADAP is paying for client’s

health insurance premiums Client presents ID card at time of

service for medical out-of-pocket cost coverage (or sends PAI a completed paper claim form)

Use

Additional Programs

• No additional programs

ADAP • OA-HIPP

PrEP-APHIV -

HIV +

• EB-HIPP • MDPP

Additional Programs – Details

ADAP• OA-HIPP — Office of AIDS Health Insurance Premium Payment program• EB-HIPP — Employer-based Health Insurance Premium Payment program• MDPP — Medicare Part D Premium Payment program

HIV +

OA-HIPP Program Details

ADAP Office of AIDS Health Insurance Premium Payment (OA-HIPP) program

HIV +

OA-HIPP Coverage Private health insurance

premiumsPlan types:• Individual, Family• On and Off Exchange• COBRA, Cal-COBRA• Dental, Vision-combination plans

Outpatient medicalout-of-pocket costs

• That count toward policy’s annual out of pocket maximum

• Example: lab or office visit co-pays

Current coverage: up to $1938* a month in premiums per client

• Payments sent to health plan

HIV +

*Subject to reassessment and adjustment annually

EB-HIPP Program Details

ADAP Employer-based Health Insurance Premium Payment (EB-HIPP) program

HIV +

EB-HIPP Coverage Employer-based health

insurance premiumsPays for:• Employee’s portion of monthly

premium• Individual, Family plans• Dental, Vision-combination plans

Outpatient medicalout-of-pocket costs

• That count toward policy’s annual out of pocket maximum

• Example: lab or office visit co-pays

Current coverage:Up to $1,938* a month in premiums per client

• Payments sent to employer• Employer must agree to participate

HIV +

*Subject to reassessment and adjustment annually

MDPP Program Details

ADAP Medicare Part D Premium Payment (MDPP) program

HIV +

MDPP Coverage Medicare insurance

premiumsPays for:• Part D premiums• MediGap premiums

(if we are paying Part D)

Outpatient medicalout-of-pocket costs

• That count toward policy’s annual out of pocket maximum

• Example: lab or office visit co-pays

Current coverage:Up to $1,938* a month in premiums per client• Payments sent to health plan

HIV +

*Subject to reassessment and adjustment annually

PrEP-AP Program Details

• No additional programsPrEP-AP

HIV -

What is PrEP ?

• Pre-Exposure Prophylaxis (PrEP)• For HIV negative individuals• Reduces the chance of contracting HIV • Truvada® is the only medication approved by the FDA for use as an HIV PrEP• Gilead Sciences, Inc. manufactures Truvada® for PrEP• Gilead has 2 assistance programs that can help individuals pay for Truvada®

1) Gilead Co-Payment Assistance Program for the insured2) Gilead Patient Assistance Program for the uninsured

PrEP-AP Coverage

Out-of-pocket costs associated with getting PrEP

• Example: HIV testing, STI screening

• Must see a provider in the PrEP-AP provider network

Rx’s on the PrEP-AP Formulary

• Truvada®•Portion of Rx cost not covered by Gilead

• Other Rx’s used to treat or prevent sexually transmitted infections (STI’s)

• Rx’s are dispensed at CDPH-Magellannetwork pharmacies

HIV -

• Applicants enroll at an ADAP enrollment site that is certified to do PrEP-AP enrollment• Applicants must be co-enrolled in one of Gilead’s assistance programs (if eligible)• Covers:

Disclaimer

CDPH, Office of AIDS is charged with coordinating stateprograms, services, and activities relating to HIV/AIDS andoperates PrEP-AP in accordance with these duties. It is notaffiliated with, and does not endorse, nor is it endorsed byGilead Sciences, Inc., or its products.

Other ADAP Initiatives

•Enroll ADAP-only clients into health insurance•Achieve and maintain HIV viral load suppression among ADAP clients

HIV + HIV -

Access, Adherence and Navigation

•Enroll ADAP-only clients into health insurance•Achieve and maintain HIV viral load suppression among ADAP clients

Done via Access and Adherence Navigators

• Outreach to non-virally suppressed clients

• Outreach to ADAP-only clients (uninsured)

• Assess barriers• Refer for services• Accompany to

appointments• Provide Rx pick-up

reminders

• Enroll clients into health insurance, Medi-Cal, or Medicare, and ADAP insurance assistance program (as applicable)

1 2 3

HIV +

Goal

Getting to Zero

•Zero new HIV Infections•Zero AIDS-related deaths

•Zero stigma & discrimination against people living with HIV

Resources• ADAP and PrEP-AP General Information –

https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OAadap.aspx• ADAP Formulary –

https://cdph.magellanrx.com/provider/external/commercial/cdph/doc/en-us/CDPH_Formulary.pdf• PrEP-AP Formulary –

https://cdphprep-ap.magellanrx.com/member/external/commercial/caprep/doc/en-us/CDPH_PrEP-AP_Formulary.pdf• ADAP Enrollment Site Locator –

https://cdphdata.maps.arcgis.com/apps/webappviewer/index.html?id=e5a93c8e3f03424d8a414adf78c76e37• PrEP-AP Enrollment Site and Provider Locator –

https://cdphdata.maps.arcgis.com/apps/webappviewer/index.html?id=6878d3a1c9724418aebfea96878cd5b2• List of OA ADAP Advisors by County –

https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_adap_advisor_by_enroll_site.aspx• List of OA Insurance Assistance Program Advisors –

https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_adap_hipp_staffassignments.aspx• Laying a Foundation for Getting to Zero: California’s Integrated HIV Surveillance, Prevention, and Care Plan –

https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/IP_2016_Final.pdf• Contact Information –

PAi (insurance benefits manager) – (877) 495-0990 (Mon – Fri, 8 am – 5 pm)Magellan Rx (prescription benefits manager) – (800) 424-5906 (24/7)ADAP Call Center – (844) 421-7050 (Mon – Fri, 8am – 5 pm)

Questions or Comments ?