When a drug is not covered by an ACA insurance company’s published formulary, the provider must complete a Medication Exception request through the insurance company providing all required information. The ACA provides for expedited review (within 24 hours) in exigent circumstances, which is when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or the ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a non-formulary drug.
As part of the request for an expedited review based on exigent circumstances, the prescribing physician or other prescriber should support the request by including an oral or written statement that:
1. An exigency exists and the basis for the exigency (that is, the harm that could reasonably come to the enrollee if the requested drug were not provided within the timeframes specified by the issuer's standard drug exceptions process), and
2. A justification supporting the need for the non-formulary drug to treat the enrollee’s condition, including a statement that all covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
If the Medication Exception request is denied, the provider must file an appeal within 24 hours and follow up with the insurance company. VDH requests in all cases where a drug exception has been denied that the Bureau of Insurance Ombudsman be contacted:
• By Toll free phone at: (877) 310-6560, select option 1
• By fax at: (804) 371-9944
• By letter at: Office of the Managed Care Ombudsman, Bureau of Insurance, P.O. Box 1157, Richmond, Virginia 23218
• By email: firstname.lastname@example.org
With the implementation of insurance through the Affordable Care Act (ACA), there have been updates to certain Virginia ADAP policies. Click here to view updated policies.
Client Cost Shares for Costs Other Than Medications
VDH recognizes the importance of supporting clients in meeting cost share requirements under insurance, as Ryan White clients typically have low incomes and the ability to access care is critical. Community partners are encouraged to continue to evaluate the use of the other Ryan White funding (Parts A, C and D) and the anticipated increases in revenue from insurance reimbursements to address client cost shares (other than the premium and all medication costs covered through ADAP). Avoiding a medication wait list is ADAP’s first priority. Unfortunately, the increasing ADAP need requires most of the Ryan White Part B award to be directed to ADAP. Additional federal and state resources are being sought to meet an anticipated program shortfall. After assuring clients will continue to have uninterrupted access to medications, VDH will re-evaluate the provision of funds available to further offset client cost shares for medical care. Until then, VDH appreciates the efforts of community partners in evaluating the use of their other Ryan White funding and their increased insurance revenue. Clients should work directly with their medical providers around addressing medical visit and lab cost sharing, as those arrangements will differ site to site.
Pre-Existing Condition Insurance Plan (PCIP) Update
PCIP coverage has been extended to April 30, 2014 for those clients who are currently enrolled in PCIP but have not yet enrolled in an ACA plan. VDH will continue to pay PCIP premium payments and costs for those PCIP clients not enrolled in ACA plans until those clients are enrolled in an ACA plan.
ADAP Central Office will begin conducting 6 month recertification during client’s birth month and every 6 months thereafter. VCU-HS will conduct recertification according to this model as well.
The ADAP Wait List has been eliminated. All financially eligible clients regardless of CD4 count may enroll into ADAP.
All individuals on the waitlist with a CD4 count above 500 will be enrolled into ADAP. New clients with a CD4 count above 500 will be temporarily placed on the wait list until all wait listed clients are enrolled to ADAP. All new clients, regardless of CD4 count, will be enrolled directly to ADAP by September 10. Please contact ADAP toll free at (855) 362-0658 for information about medication access resources for new clients.
All individuals on the waitlist with a CD4 count at or below 500 and those newly presenting to Virginia ADAP with a CD4 at or below 500 may enroll directly into ADAP. In December 2011, VDH began enrolling individuals from the waitlist with CD4 counts between 351 and 500 by the date they were put on the waitlist.
As of April 2, 2012 ADAP enrollment criteria includes the following:
Update to Policy on ADAP-Eligible Clients with Medicare Part D - March 29, 2012
Serving clients through the Medicare Part D Patient Assistant Program (MPAP) results in substantial cost-savings to the AIDS Drug Assistant Program (ADAP). Because there is a limit on out of pocket costs for clients (which MPAP pays on their behalf), approximately 3 clients are able to be served for every 1 client served through traditional ADAP. This allows ADAP to serve more clients who have no other coverage for medications.
Medicare eligibility status for ADAP-eligible clients is assessed at initial eligibility determination and every six months. ADAP-eligible clients who are also eligible for Medicare are instructed to enroll in a Medicare Part D plan. ADAP clients with household incomes less than 150% of the Federal Poverty level (FPL) must apply for the low-income subsidy (LIS) or “extra-help” component of the Part D benefit to assist with out-of-pocket costs. Medications can be accessed through the MPAP under ADAP until LIS eligibility determination is received. Clients who qualify for the full LIS are not eligible for MPAP/ADAP assistance.
Clients and their HIV providers will be notified by letter if disenrolled from ADAP due to declining MPAP services or declining to apply for Medicare Part D. A copy of the letter will be maintained in the closed client file.
As of December 22, 2011, ADAP enrollment criteria includes the following:
Applicants who do not meet one of these criteria will be put on a wait list.
Update to Dispensing Policy - Dec. 17, 2010
Effective immediately, all ADAP prescriptions will be dispensed for a supply not to exceed 30 days. The LHS-181 will still be completed by the local ADAP coordinator or designated staff but cannot exceed a 30-day supply. Please keep in mind that antiretroviral prescriptions will have a refill maximum of six months and prescriptions for greater than 30 days will not be dispensed.
This change is necessary due to the current ADAP funding shortfall which has necessitated the need to transition some clients to pharmaceutical manufacturers'' patient assistance programs. Limiting the supply to 30 days provides tighter inventory control, reduced medication wastage if regimens change, and ensures clients are receiving equitable access to medications. Historically, about 20% of ADAP prescriptions were for a 90-day supply, but we have seen a recent increase in 90-day prescriptions. If you have any questions about this change, please contact Pharmacy Services at 804 786-4326.
Program Changes Effective November 2010
More Information About These Changes
Library of Policy Updates & Program Memos
ADAP Data Reports
ADAP Evacuee Policies and Application
In the event a disaster necessitates that Virginia assists evacuees from other states, please follow and utilize the following documents: (1) Virginia’s ADAP Evacuee Policy and (2) the Virginia ADAP Emergency Relief Application.
Questions or comments?
Medication Eligibility Hotline 1-855-362-0658