The Illinois Department of Public Health administers the AIDS Drug Assistance Program (ADAP), which currently serves on average 4,100 clients each month, accessing an average of 141,100 prescriptions annually.
Starting June 1, 2011, ADAP provides 81 different drugs on its formulary, including all anti-retroviral therapies approved by the U.S. Food and Drug Administration. Clients have a benefit cap of $2,000 per month, except for 3 drugs in Category V, which is sufficient to support triple and quadruple combination therapies. These drug combinations have been successful in treating persons with HIV infection; including the treatment of opportunistic infections frequently associated with HIV; drug treatment adherence; and have been credited with dramatic prolonging of life for individuals infected with HIV.
Clients approved for ADAP must re-apply every 6 months in order to continue to receive services.
To qualify for ADAP services, a person must meet the following criteria:
- Be diagnosed as having AIDS or HIV;
- Complete the Department’s ADAP Online Application;
- Qualify financially, which will be accessed as follows using the current Federal Poverty Level published annually by the U.S. Department of Health and Human Services for the size of the household (federal poverty level for the size of the household):
- New Applicants as of July 1, 2011 — ALL “new” applicants and those previously enrolled clients whose status is classified by ADAP as “closed” at the point of enrollment will be assessed at an income threshold of 300% of the federal poverty level (FPL).
- Active Applicants enrolled in ADAP prior to July 1, 2011 — ALL applicants that are classified as “active” with ADAP prior to July 1, 2011, will be assessed at the initial federal poverty level (FPL) determined by ADAP prior to July 1, 2011, but not to exceed 500% FPL.
- If an active ADAP applicant enrolled prior to July 1, 2011, fails to reapply during the required reapplication time period and becomes “closed”, the applicant will then be reassessed at 300% FPL standard.
- Applicants applying with active prescription insurance as of July 1, 2011 — ADAP will retain the 500% federal poverty level (FPL) for those applicants that apply to the program with active prescription insurance plan(s) (i.e., prescription insurance, Medicare Part D, Illinois Comprehensive Health Insurance Program [ICHIP], Illinois Preexisting Condition Plan [IPXP], or Illinois Cares Rx [ICRx]). The 500% FPL guideline will apply to all new and reapplying clients with active insurance coverage.
- Applicants applying that are over 300% of the federal poverty level as of July 1, 2011 — Applicants over the 300% FPL applying for ADAP as of July 1, 2011, with no health insurance coverage will be encouraged to apply for the Illinois Preexisting Condition Plan (IPXP), which is a state operated insurance program. Upon enrollment into IPXP, clients will be classified as “insurance clients” and be eligible for the Insurance Program with ADAP. ADAP will assist IPXP clients by paying the $1,600 prescription out-of-pocket cost for all ADAP approved formulary drugs.
- ADAP Applicants who qualify for IPXP are eligible to apply for the Continuation of Health Insurance Coverage (CHIC) Program through the Illinois Department of Public Health. CHIC will assist clients by paying up to $500 towards the IPXP monthly premium cost as long as their income level does not exceed 500% FPL.
- If applicant has no income or income $500 or less, documentation of support must be included (Letter of Support form);
- Not eligible for medical assistance through the Illinois Department of Healthcare & Family Services, Medical Assistance Program on the date drugs are obtained. [Individuals with a financial/medical assistance application pending or in a spend-down unmet status may participate];
- If eligible for health insurance coverage, the company must be willing to participate with the contracted dispensing pharmacy for dispensing and billing purposes and only drugs on the ADAP Formulary will be covered. In addition, applicant’s insurance company cannot mandate greater than 30 day medication fills. If either of these two requirements are not compatible with the applicant’s insurance policy, then the applicant is NOT eligible for ADAP services (provide a clear copy of the front and back of the insurance card);
- If applicant is Medicare Part-D (prescription drug plan) eligible, then provide a clear copy of the front and back of the Medicare Part-D insurance card;
- If applicant is Federal Extra Help and Illinois Cares Rx eligible, applicant is required to apply to both programs and approval/denial letters are required to be forwarded to ADAP; and
- Be a resident of and domiciled in Illinois.
All ADAP applications are reviewed and approved by
program staff after verification of information provided on the application. Only signed and completed forms with required documentation will be processed. Completed applications are to be accompanied with proof of:
- most recent CD4 and Viral Load test results, and
- residency, such as a copy of a utility bill, valid driver's license or state I.D. card.
addition, a cross-match with the Medicaid database is done to ensure that
applicants are not currently eligible for that program.
All ADAP drugs are currently purchased directly from
Amerisource Bergen Drug at a discounted price and shipped to
Pharmacy, for dispensing.
Prescriptions must be sent or faxed to
Pharmacy and clients receive their drugs via mail order. Clients must contact
Pharmacy each month to confirm shipment date for the next scheduled
Important Update for ADAP Clients Eligible for Medicare Part D Prescription Insurance
With the recent signing of the Federal Health Care Reform Act in July 2010 by President Obama, all AIDS Drug Assistance Programs Nationally are legislatively required on January 1, 2011 to begin reporting assistance provided to Medicare Part D clients in order to ensure that ADAP assistance is being appropriately applied towards the client’s True-Out-Of-Pocket (TrOOP) costs. This legislation changed the landscape for direct purchase states and how Illinois ADAP provides assistance to Medicare Part D eligible clients (Section 3314 of the Affordable Care Act amended 1860D-2(b)(4)(C) of the Social Security Act; The Affordable Care Act, Public Law is 111-148).
Starting January 1, 2011, Illinois ADAP clients who are Medicare Part D eligible will no longer receive drugs out of Illinois ADAP’s direct inventory. Instead, Illinois ADAP will begin to assist with paying client’s Medicare Part D deductible and copayments for drugs on the Illinois ADAP Formulary. These contributions will be applied to the client’s True-Out-Of-Pocket (TrOOP) costs by Illinois ADAP’s Prime Benefit Manager (PBM) at the point of purchase/dispense. In essence, Illinois ADAP will be assisting with the following for Medicare Part D classified clients for drugs approved on the Illinois ADAP Formulary:
The initial $310 Medicare Part D deductible for approved ADAP Formulary drugs only,
Copayments applied to the true-out-of-pocket (TrOOP) cost not to exceed $2,830, which is associated with leading up to the “Medicare Part D Donut Hole” for approved ADAP Formulary drugs only,
Once in the “Medicare Part D Donut Hole” copayments applied to TrOOP cost for drugs up to $4,550 required to move client through the “Medicare Part D Donut Hole” for approved ADAP Formulary drugs only, and
Once through the “Medicare Part D Donut Hole” and classified as a Medicare Part D client at catastrophic level, ADAP will assist with the 5% copayments for ADAP Formulary approved drugs only.
IMPORTANT FACT: As Illinois ADAP begins to contribute towards a client’s Medicare Part D TrOOP costs for ADAP Formulary approved drugs only, clients will begin to see themselves reaching the “Medicare Part D Donut Hole” sooner than in previous years. More importantly, during the time that a Medicare Part D ADAP client is in the “Medicare Part D Donut Hole” any medications that are outside the ADAP Formulary will be the responsibility of the client (which usually will be 100% retail cost of the medication; i.e., all non ADAP Formulary drugs).