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ADAP Session 2 by benbenzhou


									Texas HIV Medication Program

                 Becky Ruiz, BSW
             Katherine Wells, MPH
Presentation Outline
    HIV Medication Assistance in Texas
    Overview of the Texas HIV Medication
     Program (THMP)
    Application Process
    Discussion of problem areas on the THMP

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March 6, 2009
Help with Medications in Texas
    Private Insurance
    Patient Assistance Programs
    Texas High Risk Pool
    City and County Assistance Programs
    Medicare
    Medicaid
    Texas HIV Medication Program
          AIDS Drug Assistance Program (ADAP)
          State Pharmacy Assistance Program (SPAP)
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Patient Assistance Programs
    Run by the individual drug manufacturers
    Provides free and/or reduced cost medications to
     eligible individuals
    These programs cover HIV Medications as well as
     medications used to treat side effects and other
    Some of the major HIV manufacturers are planning
     to start assisting with insurance co-pays
    Helpful websites:;
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Local Drug Assistance
    Ryan White Funding, Parts A, B, C & D
    State Services
    County Funds
    Local Programs: Carelink (San Antonio),
     MAP Card (Travis County), Gold Card (Harris

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    Federal program that provides medical care for the
     elderly and disabled
    Medicare includes 4 different programs
          Part A – Hospital Insurance
          Part B – Medical Insurance, individuals must select the
           program and pay a monthly premium ($96.40)
          Part C – Medicare Advantage Plan, provides Part A and
           Part B benefits through a private company, may provide
           prescription coverage
          Part D – Prescription Drug Benefit, individuals must enroll
           in an approved plan and pay a monthly premium (avg. $25)
    Additional information: or 1-800-
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    A state program that provides medical assistance to
     low income individuals
    Medicaid can provide:
          Medical Care
          Prescription Drugs
          Health Insurance Premium Payments
          Assistance with the Medicare Part B premium –
    Income limits are higher for children and pregnant
    For more information call 2-1-1 or 1-877-541-7905
     or online at
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March 6, 2009
Texas HIV Medication Program
    Administered by the HIV/STD
     Comprehensive Services Branch within the
     Department of State Health Services (DSHS)
    Mandated under Chapter 85 of the Health
     and Safety Code
    Authorized by the Federal Ryan White CARE
     Act, 42 USC, Section 300

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March 6, 2009
Texas HIV Medication Program
    Program established in 1987
    Provides life-sustaining medications used for the
     treatment of HIV disease and its related
     complications to low income Texans
    Key philosophies –Access to care and Retention in
    Consists of two programs
          AIDS Drug Assistance Program (ADAP)
          State Pharmacy Assistance Program (SPAP)
    4th Largest ADAP (NY, CA, FL)
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March 6, 2009
Current Enrollment
    11,651 currently enrolled clients
          10,738 enrolled in the ADAP
          913 enrolled in the SPAP
    13,108 clients served in State FY08
    Program is open to new enrollment/No waiting
    Clients served has increased significantly from
     5,106 in 1996 to the 13,108 in 2008
    The THMP dispensed over $75 million in
     medications to eligible clients in SFY2008
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March 6, 2009
THMP Eligibility
    Texas resident
    HIV-positive
    Uninsured or underinsured for prescription drugs
    Low income – Adjusted gross income less than
     200% of the Federal Poverty Level (2009)
          $21,660/year for a single person
          $ 7,480/year for each + family member

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Application Process
    Fill out the THMP application
          Application and Instructions can be downloaded
           from the web:
           or contact the THMP to have packet sent
    Have the Medical Certification Form (MCF)
     filled out by doctor
    Mail the application and supporting
     documentation to the THMP

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March 6, 2009
Application Process
    Applications are typically processed within 2 to 3
     business days of receipt
    The applicant and/or their designated authorized
     person will be contacted by THMP staff if further
     information is needed.
    Once the application is processed, the applicant will
     be notified of the decision by mail.
    If denied by the THMP, the denial letter can be used
     to access other assistance programs
    Clients are required to recertify for the program
     (ADAP: every 3 years, SPAP: every other year)
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March 6, 2009
Expediting Applications
    In some instances applications can be expedited.
     This means the application can be faxed instead of
          Pregnant Women
          Children under 18 years of age
          Recently Incarcerated
          Special Situations – call the program to discuss the
           situation before faxing
    Note: In order for an expedited application to be
     approved it must be complete and the applicant
     must meet all eligibility guidelines.

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                     Texas HIV Medication Program

                                            Texas HIV
                AIDS Drug
                                        State Pharmacy
           Assistance Program
                                       Assistance Program
           Clients not eligible
                                         Clients eligible
               for Medicare
                                          for Medicare

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Texas ADAP
    Funded by Ryan White and State General
    Provides ADAP formulary medications to
     eligible individuals
    Medications are distributed through a network
     of pharmacies

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March 6, 2009
Texas ADAP Formulary
    42 drugs/80 different formulations
    All FDA approved ARVs on formulary
    Limited scope-includes 10 of the 14 PHS
     recommend drugs for the treatment & prevention of
     OIs – no drugs to treat side effects of toxicities
    Medical criteria for the majority of drugs
    Limits on the number of antiretroviral medications a
     client can receive (4 per month)

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Accessing Medications
    Medications are distributed through a network of
     community pharmacies
    Pharmacies may charge a $5.00 dispensing fee per
    A pharmacy cannot refuse service if a client is
     unable to pay
    A list of participating ADAP pharmacies can be
     found at:

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March 6, 2009
Approved on ADAP –
What happens now?
    The ADAP enrollee receives an approval letter that
          Name and Address of Assigned Pharmacy
          List of approved medications
          Client ID number
    The assigned pharmacy receives the same letter
    ADAP client takes their prescriptions to the assigned
     pharmacy and lets the pharmacy know they are part
     of the Texas HIV Medication Program
    Pharmacy will verify prescriptions and order
     medications from the THMP
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What happens now?
    THMP receives medications order via fax and phone
     at the office in Austin
    THMP order staff verify the client is enrolled in the
     program, approved for the medications and if the
     client has active Medicaid
    If the order is denied the pharmacy is notified,
     common reasons for denial include:
          Client not approved for the Medication
          Client has open Medicaid slots
          Client is on HOLD

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What happens now?
    If the order is approved, the medication orders are
     batched and sent to the DSHS pharmacy.
    The DSHS pharmacy packs the medications
     ordered from the local pharmacy and ships the
     medications via UPS
    The medications arrive at the pharmacy, the
     pharmacist labels the medications and dispenses
     them to the client
    The process can take 3 to 5 business days,
     therefore it is important for clients to reorder
     medications before they run out of medications
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    State funded program
    Developed to assist clients with Medicare following
     the creation of Medicare Part D in 2006
    Started January 1, 2008
    Provides assistance with Medicare Part D out of
     pocket costs
    The client must be enrolled in a Medicare Part D
     plan or a Medicare Advantage Plan w/drug
     coverage to participate in the program

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March 6, 2009
Texas HIV SPAP Benefit
    The SPAP will cover the out-of-pocket costs
     for an enrollee for medications covered on
     the enrollees’ Part D plan formulary
    Out-of-pocket costs include:
               Deductible
               Co-payments
               Medications during the coverage gap
               Co-payments/coinsurance after reaching catastrophic

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March 6, 2009
Texas HIV SPAP Benefit
    SPAP enrollees can enroll in any Medicare
     Part D plan offered in Texas
    SPAP enrollees will be responsible for paying
     monthly Prescription Drug Plan Premiums
    The SPAP will assist with all medications
     covered on the individual’s Part D formulary
    The beneficiary must maintain enrollment in a
     Part D plan in order to access services from
     the THMP

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March 6, 2009
Texas HIV SPAP Benefit
    Annual allowable amount per SPAP enrollee for
     2009: $10,995
      High End Risk Example:

                        Cost       Out-of-Pocket      Part D Coverage Period
                                                 Deductible, Initial Coverage,
          Month 1        $10,000          $4,522 Coverage Gap, Catastrophic
          Month 2        $10,000            $500 Catastrophic Coverage
                                                   Catastrophic Coverage
    Month 3 -12         $100,000          $5,000   (10 months)

                Total   $120,000         $10,022

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Medicare Part D Plan
    Medicare open enrollment is from Nov 15 to Dec 31
     each year
    A one time Special Enrollment Period (SEP) will be
     available for newly enrolled SPAP clients
          Must give official SPAP name (THMP SPAP) and ID#
           (SS028) to Medicare/prescription drug plan to successfully
           enroll the client during the SEP
    Clients can enroll by:
          Calling the plan directly
          Calling 1-800-MEDICARE (633-4227)
          Online at

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Late Enrollment Penalty
    Medicare will assess a late enrollment penalty if a
     person with Medicare
          does not join a Medicare Part D plan when first eligible or
          does not have creditable coverage (THMP is not creditable
    The penalty is 1% of the national Medicare premium
     ($30.36 in 2009) for every month without creditable
    The penalty is added to the monthly drug premium
    The penalty is permanent and recalculated each
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    Bob became eligible for Medicare on April 1, 2008 but did not
     enroll in a Medicare Part D plan
    He later decides to enroll in a plan during the open enrollment
     period. His plan will be effective on January 1, 2009.
    Since Bob is without creditable drug coverage from April 2008
     through December 2008 he will be assessed a 9% penalty (1%
     for each of the 9 months he did not enroll)
    In addition to the plan premium Bob will pay an extra $2.73 each
     month (National Average Premium $30.36 x 9%)
    If Bob waits 24 months to enroll in a plan he will have to pay an
     extra $7.28 per month

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How to Enroll in the SPAP
    SPAP eligibility is determined by THMP staff
    Complete the Texas HIV SPAP Enrollment form
    Submit a copy of the LIS partial approval or denial
     letter from SSA (all pages of the letter)
    If not currently enrolled in the THMP, a complete
     THMP application must also be submitted
    Applications can be printed from the THMP website:

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March 6, 2009
Accessing Medications
    All SPAP enrollees will receive a welcome packet
     from Ramsell Holding Corp (Ramsell Public Health
     Rx) in Oakland, CA, which will include an ID Card
    Enrollee will take their ID cards (Part D Plan and
     SPAP) and prescriptions to a participating pharmacy
    Pharmacist will process prescriptions through the
     Medicare Part D Plan first
    If medications are approved, remaining out-of-
     pocket costs will be billed to SPAP as the secondary
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March 6, 2009
Low Income Subsidy/Extra Help
    Applications are processed by Social Security
          apply online at, fill out a paper
           application or call 1-800-772-1213
    To qualify for LIS the beneficiary must meet
     income and asset guidelines
    All THMP Clients with Medicare are required
     to apply for this assistance and submit a copy
     of the Social Security Determination Letter to
     the THMP
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March 6, 2009
Full Low Income Subsidy (LIS)
    100% assistance w/ premium, drug costs are
     reduced to $6.00 per prescription
    No coverage gap (donut hole) or deductible
    To qualify must have resources below $6,120 and
     income below $13,784 (135% FPL)
    Income and resource limits are adjusted annually
     and are higher for couples and families
    All people with Medicare & Medicaid or are a
     qualified Medicare beneficiary (receive QMB or
     SLMB) automatically qualify for full LIS

- Not eligible for SPAP
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March 6, 2009
Partial Low Income Subsidy
    25% to 100% assistance w/premium
    Drug costs are reduced to 15% co-pays
    No coverage gap or donut hole
    Reduced drug deductible ($0 – $60)
    To qualify resources below $10,210 and income
     below $15,315 (150% FPL) for a single person
    Income and resource limits are adjusted annually
     and are higher for couples and families

- Eligible for SPAP
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Helpful Websites
    Texas HIV Medication Program Website:
    Low Income Subsidy Application
      or 1-800-772-1213
    Medicare, including Part D Plan finder and
     enrollment information
    Ramsell Public Health Rx TX Pharmacy List
     (searchable by city, zip, or county)
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March 6, 2009
                      Problem Areas
                 on the THMP Application
    Missing or inadequate verification of income
    Unclear or incomplete representation of
     household situation, family members, and/or
     marital status
    Invalid proof of Texas residency
    Insurance/prescription coverage issues
    Missing or incomplete Medical Certification
     Form (MCF)
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March 6, 2009
What You Can Do To Help
    The client is encouraged to explain in writing as
     much as possible to clarify any part of the
     application pertaining to them, especially:
          Household information
          Marital status (if separated, give detailed information
           about how long, where spouse is, etc.)
          Employment situation, especially if not employed (written
           explanation of when/where last employed)
          Support documentation, if zero income a completed
           THMP Supporter Statement is preferable or any other
           written support document or statement

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March 6, 2009
What You Can Do To Help
    Note that additional documentation from YOU
     (Social Workers, Case Managers, LVN’s, RN’s) will
     continue to be needed to clarify any unusual or
     complicated situations a client may be in
    Applications must be completed fully, no blank
     spaces or marks across pages or areas, please
     answer each question completely
    If either you or the client is uncertain about what the
     THMP requires in a given situation, please call 1-
     800-255-1090 and request clarification from our
     eligibility staff
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March 6, 2009
THMP Contact Information
Phone: 1-800-255-1090 or 512-533-3000
        Staff        Extension                    Area of Expertise
 Becky                 3006      Case Management, Eligibility, Medicare
 Christine             3003      Recertification Lead
 Juliet                3004      SPAP Lead
 Jack                  3012      Incarcerated Populations
 Katherine             3008      SPAP
 Kelley                3011      Order Processing Lead
 Krystal               3009      Eligibility
 Stacy                 3007      Eligibility

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March 6, 2009

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