AIDS Drug Assistance Program (ADAP)
What Is ADAP Assist?
ADAP Assist is co-pay assistance for ADAP clients who have private insurance, Medicare, or pre-existing condition insurance plan Pre-existing Condition Insurance Plan (PCIP). When we receive an ADAP application for a client who is insured or eligible for insurance, we ask for premium, formulary and co-pay information. ADAP needs this information to determine whether the coverage is adequate and affordable. Adequate means the insurance will cover the antiretroviral (ARV) drug therapy. Affordability is determined by adding the yearly premium and co-pays and comparing the total to the Health Resources and Services Administration (HRSA) affordability guidelines (see below). If the client’s premium and co-pays for the year are more than 5 or 7% of their income, then the insurance is deemed unaffordable and the client is enrolled in ADAP Assist. If premium and co-pays are affordable, then the client will not be eligible for ADAP Assist.
- 100-199% Federal Poverty Level (FPL) = 5% of annual income = affordability
- 200-300% FPL = 7% of annual income = affordability
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Please click on the frequently asked questions below to see their answers.
What Medications Are Available Through ADAP Assist?
Are there certain medications that ADAP Assist does not cover?
ADAP Assist cannot pay copays for the following medication categories:
- All Over The Counter drugs
- Erectile Dysfunction (ED)
- Fertility Agents
- Skin Coloring Agents
- Retinoids (Retin-A, Differin, Accutane, Others)
- Hydroquinone (Eldoquin, Others)
- Prescriptions used for cosmetic purposes
- Ancillary supplies
Are there certain medications that require prior authorization?
Some medications available through ADAP Assist require prior authorization. The following medications require prior authorization:
What is PCIP?
The Pre-Existing Condition Insurance Plan (PCIP) is a health coverage option for people who have been without health coverage for at least six months, have a pre-existing condition, or have been denied health coverage because of their health condition, and are U.S. citizens or are residing in the U.S. legally.
PCIP falls under the ADAP Assist umbrella. The difference with PCIP is that the program not only pays for medication co-pays, but also pays premiums and medical co-pays. In order to be eligible for PCIP, the client must be uninsured for the last six months and legally present in the U.S.
ADAP Assist clients on PCIP need to work with Kelly Morrow and Neil MacDonald at SAAF (520-628-7223) for medical bill submissions.
As of February 15th 2013, PCIP has suspended enrollment in order to continue services for currently enrolled clients until the implementation of the Affordable Care Act in 2014.
Are There Certain Medical Expenses That ADAP Does Not Cover Under PCIP?
ADAP does not cover inpatient care, emergency care, cosmetic procedures or care, fertility procedures or care, gender reassignment procedures or care, or care related to erectile dysfunction or sexual performance.
What If I Have Medicare?
If you are eligible for Medicare, you must sign up for Medicare Part D prescription coverage and provide us with a copy of your Medicare prescription card or a copy of a letter from the company that provides your drug plan. You are also required to provide a copy of the current determination letter from the Social Security Administration (SSA) Medicare Prescription Drug Assistance Program that shows you are not eligible or only partially eligible for Extra Help (low-income subsidy [LIS]). ADAP will provide a 45 day provisional enrollment pending receipt of a copy of your Medicare prescription card and/or your LIS determination letter.
What pharmacies can I use?
ADAP Assist clients may choose to use Avella Specialty Pharmacy (formerly The Apothecary Shops) at (866) 881-4902 each time they need a refill. You may also contact Ramsell to find other pharmacies that you can use. We anticipate more choices to be added in March 2013. Ramsell Corporation is a pharmacy benefit manager (PBM), which means they assist in processing prescription drug claims. They are experienced in serving people living with HIV/AIDS and work with ADAPs throughout the United States.
How do I use my prescription card from Ramsell?
ADAP Assist clients will receive a prescription card in the mail. They will show their prescription card to the pharmacist when filling their prescription. It gives important information about ADAP Assist eligibility. Pharmacists will connect with Ramsell by computer to check eligibility and get approval to fill prescriptions.
Do I need a copy of my prescriptions from my doctor?
Yes. Clients on ADAP Assist are responsible for ensuring their pharmacy of choice receives their prescriptions. Clients on ADAP Assist may have their physician fax their prescriptions to the pharmacy of choice or provide the original signed page 5 from the ADAP application to their pharmacy. ADAP Assist clients can have their preferred pharmacy call Avella and have their prescriptions transferred. If the prescriptions are for controlled substances, clients should ask their physician for assistance in transferring the prescription. ADAP will fax prescriptions to Avella Specialty Pharmacy for ADAP Assist clients upon request.
Do I need to complete my ADAP renewal?
Yes. There is a 6 month and 2 year ADAP Assist renewal process.
Can I use mail order options?
Yes. Clients on ADAP Assist may elect to fill though Avella Specialty Pharmacy to have their medications shipped to them at no cost, or may choose another pharmacy to deliver their medications at their own expense.
Can I get a 90 day supply?
No. Due to federal regulations, clients on ADAP Assist can still only receive 1 month of medication at a time.
I know someone on the regular ADAP program. Will they be able to fill medications through an ADAP assist pharmacy?
No. Clients on traditional ADAP are still required to fill their medications through Avella Specialty Pharmacy.
What if I have additional questions?
If you have any further questions or concerns about the ADAP Assist Program or Ramsell, you may call us at (800) 334-1540 or (602) 364-3610. Please ask to speak to the ADAP coordinator.