North Carolina AIDS Drug Assistance Program (ADAP) State Pharmaceutical Assistance Program (SPAP)

What is an SPAP  State Pharmaceutical Assistance Program (SPAP)  Special designation by CMS  Data sharing between ADAP and CMS  Medicare eligible clients on ADAP identified  Low Income Subsidy (LIS) status identified  Federal Poverty Level identified  State funds used to pay cost sharing  RW (federal) funds currently don’t count toward meeting TrOOP

Medicare Part D – Brief Overview  Medicare Prescription Drug Benefit  Started in 2006  Provides prescription drug coverage for anyone Medicare eligible  Individual signs up for a PDP  May be eligible for LIS through Social Security – separate application  All HIV drugs (ARVs) covered (CMS requirement)  Premiums vary, deductibles vary ($0 - $295)  Cost sharing varies (copays, coninsurance, donut hole) – called TrOOP

Medicare – Brief Review  True-Out-Of-Pocket (TrOOP) Costs  Individual’s responsibility for their medications  Deductible  Percentage of the medication cost  Copays  Donut hole (coverage gap – individual pays entire cost of the medication)

Medicare – Brief Review  The Donut Hole – What is it?  Individual pays the entire cost of medications  How does an individual get into the donut hole?  The total medication cost is used to move the person into the donut hole – what the drug plan pays and what the person pays (copay/coninsurance)  To get into the donut hole = $2700 total drug costs  To get out of the donut hole = $4350 completely paid by the person

Why An SPAP?  In 2006 – ADAP was approved to continue covering the Medicare eligible clients even though clients had prescription drug coverage – Why?  May have resulted in medication gaps since donut hole is unaffordable for most  Clients would have been worse off with the new PDP – coverage level much less  Potential for increased transmission of HIV if viral load is not maintained at a low or undetectable level

Why An SPAP?  As an ADAP  Cannot use Ryan White (federal) funds to coordinate with Medicare Part D  Provided medication regimen at the full cost to ADAP  Medication costs not coordinated with or reported to Medicare  As an SPAP –  State funds used to pay the TrOOP on behalf of the client for all drugs on the ADAP formulary  Copays, coinsurance, donut hole paid for by ADAP  Costs reported to Medicare TrOOP facilitator  No cost to client for drugs on the ADAP formulary

What is Required for Medicare Eligible Clients on NC ADAP  Must meet NC ADAP eligibility criteria  Must sign up for a Medicare Part D PDP or Advantage Plan with Prescription Drug Coverage  Client pays premium – averages $30/month  Client pays copay or co-insurance for non-ADAP formulary drugs  If below 150% of the federal poverty level must sign up for the low income subsidy (LIS) through Social Security

NC SPAP Process  Same central pharmacy used for both ADAP and SPAP clients  Original pharmacy contract required that Medicare and Medicaid eligibility are checked at time of medication dispense  If Medicare eligible – dispense processed through the PBM  TrOOP facilitator updated real-time  Billing separate – only state funds used for clients on SPAP  Dispensing reports separate

Benefits of SPAP  ADAP pays only the client’s TrOOP for drugs on the NC ADAP formulary (copays/coninsurance/donut hole)  All costs paid on behalf of client are reported to the Medicare TrOOP facilitator  Helps move client into catastrophic coverage level  Saves a significant proportion of the costs previously expended for the client’s regimen as a regular ADAP client  Helps ensure open enrollment into ADAP  Allows for additional services, such as adherence counseling  Allows for an expanded formulary

Challenges  NC ADAP information about Medicare eligible clients was incomplete  Educating Case Managers about Medicare Part D and the SPAP  Enrollment not during normal open enrollment period  Contacting Clients  Ensuring enrollment into Part D  Resistance from clients and case managers  Non-ADAP Medication Costs  CMS Data Files  Medications not on Medicare PDP formulary

Questions?  Sally Kohls: or  Robert (Bob) Winstead: or  NC ADAP Website ml ml ml