1. Health and Wellness for all Arizonans azdhs.gov 2015 ADAP Overview Lisa Fuentes Ryan White Part B Program Manager Jimmy Borders, ADAP Operations Manager

2. Health and Wellness for all Arizonans azdhs.gov Ryan White Part B/ADAP Team Lisa Fuentes HIV/AIDS Care Services Manager Lora Andrikopoulos RW Fiscal Monitor Jimmy Borders ADAP Operations Manager John Lick RW Quality Manager David Balkcom RW Data Manager Vacant Reengagement in Care Specialist Laura Kroger Retention Coordinator LisaMarie Bates ADAP Admin Assistant Louisa Vela ADAP Eligibility Coordinator Claudia Cardiel ADAP Eligibility Coordinator Jessica Alvidrez ADAP Eligibility Coordinator Lynelle Dorsey- Brooks RW Data Manager Greg Romero ADAP Eligibility Coordinator Megan Swanson HIV Surveillance Epidemiologist

3. Health and Wellness for all Arizonans azdhs.gov ADHS RWPB & ADAP The RWPB Care & Services Program Manager, Lisa Fuentes, is responsible for the oversight and management of the RWPB Program and is the direct supervisor of the ADAP Program Manager. The ADAP Program Manager, Jimmy Borders, is responsible for the day to day operations of the ADAP Program which includes ADAP Assist, MTM, MBM, PBM and 340B pharmacy.

4. Health and Wellness for all Arizonans azdhs.gov ADAP Eligibility Client must be diagnosed as HIV-positive Client must be a resident of Arizona with acceptable documentation provided. Client’s Modified Adjusted Gross Income (MAGI) cannot exceed 400% of federal poverty level (FPL) with acceptable documentation provided. – For example, in 2015 a client cannot have an annual income of more than $47,080 for a household size of one. Client cannot be eligible for AHCCCS (Arizona’s Medicaid agency) Acute care coverage only. – To ensure that Ryan White Part B is the payer of last resort for ADAP, all individuals applying, not deemed FFM eligible, will need to screen for AHCCCS eligibility and submit an AHCCCS denial, if applicable.

5. Health and Wellness for all Arizonans azdhs.gov ADAP Enrollment Process For initial application and/or birthday renewals, the client and/or Case Manager must submit the most current version of the ADAP application found at – English version at http://www.azdhs.gov/phs/hiv/documents/adap/ADAP-application- english.pdf http://www.azdhs.gov/phs/hiv/documents/adap/ADAP-application- english.pdf – Spanish version at http://www.azdhs.gov/phs/hiv/documents/adap/adap-application- es.pdf http://www.azdhs.gov/phs/hiv/documents/adap/adap-application- es.pdf For ½ birthday renewals, the client and/or Case Manager must submit the ½ birthday renewal notice along with Medical Provider Page (MPP) found in CAREWare under the client’s forms.

6. Health and Wellness for all Arizonans azdhs.gov ADAP The Arizona Department of Health Services (ADHS) is responsible for the administration of ADAP for the State of Arizona. ADAP (a.k.a. “Straight ADAP”) provides access to 340B medications used to treat HIV and prevent the onset of related opportunistic infections to low- income individuals who have limited or no coverage from private insurance or Medicaid.

7. Health and Wellness for all Arizonans azdhs.gov ADAP 340B Pharmacy ADAP 340B medications are dispensed through Avella Specialty Pharmacy in Central Phoenix. – The headquarters of Avella Specialty Pharmacy is in Phoenix. Medication can be picked up in person or shipped directly to ADAP-eligible clients' homes. There is also the option to pick up medications shipped to any other Avella Specialty Pharmacy locations throughout Arizona.

8. Health and Wellness for all Arizonans azdhs.gov ADAP Assist ADAP Assist is prescription (Rx) co-pay assistance for ADAP clients who have private insurance including those from the Federally Facilitated Marketplace (FFM), Medicare, or employer-sponsored. Co-pay assistance is provided through our prescription benefits manager (PBM) Ramsell after the client’s primary insurance has paid their share of the Rx. When an ADAP application is received for a client who is insured or eligible for other insurance including the FFM, ADAP asks for premium and formulary information. ADAP needs this information to determine whether the coverage is adequate. – Adequate means the insurance is affordable and meets/exceeds the essential health benefits (EHBs) as demonstrated through all FFM health insurance. Clients desiring to opt-out of their employer-sponsored private insurance in lieu of enrollment into the FFM, can only do so: – When/if the employer-sponsored private insurance premium annual cost exceeds 9.56% of the annual household income for the enrollee – When/if the employer-sponsored private insurance EHBs are deemed inadequate Medicare eligible clients DO NOT have the ability to opt-out

9. Health and Wellness for all Arizonans azdhs.gov Ramsell Prescription Benefit Manager (PBM) ADAP Assist clients may choose to use Avella Specialty Pharmacy each time they need a refill. Clients may also contact our PBM, Ramsell, to find other pharmacies that can be used in conjunction with their primary insurance. – Client is responsible for ensuring his or her pharmacy accepts both their primary insurance and Ramsell ADAP Assist coverage Ramsell will send new ADAP Assist clients their ID cards upon enrollment. Replacement ID cards can only be issued by ADAP. Clients can contact ADAP at 602-364-3610 to request a replacement ID card. Ramsell can be reached at 888-311-7632 or at http://www.ramsellcorp.com/individuals/az.aspx http://www.ramsellcorp.com/individuals/az.aspx

10. Health and Wellness for all Arizonans azdhs.gov Medications Covered and/or Excluded ADAP Assist covers medication co-pays paid for by the primary insurance company with the following exceptions: Certain Over The Counter (OTC) drugs Erectile Dysfunction (ED) Fertility Agents Contraceptives Skin Coloring Agents Retinoids (Retin-A, Differin, Accutane, Others) Hydroquinone (Eldoquin, Others) Prescriptions used for cosmetic purposes Certain ancillary supplies

11. Health and Wellness for all Arizonans azdhs.gov Prior Authorization ADAP formulary committee rules mandate the following medications require prior authorization from ADHS before copays will be covered: Egrifta (tesamorelin) Serostim Fuzeon (ENF, Enfuvirtide)* Valcyte (Valganciclovir)* Medication specific PA forms available at http://www.azdhs.gov/phs/hiv/adap/assist.htm http://www.azdhs.gov/phs/hiv/adap/assist.htm * PA requirement up for review at April 2015 ADAP Medical Advisory Committee meeting

12. Health and Wellness for all Arizonans azdhs.gov FFM Guidelines for Statewide Clients Silver plans only APTC must be determined and paid up front In-network cost only; no out-of-network costs covered Premium Assistance up to $350 per month Deductible/Medical Copay Assistance up to $3000 per year – Must obtain medication through participating pharmacy in Ramsell Network – Unable to pay for ER or inpatient services – Date of Service must be within current grant year (April 1-March 31) – Must be HIV-related

13. Health and Wellness for all Arizonans azdhs.gov FFM Guidelines for Statewide Clients (Cont.) Clients who are not ADAP eligible are responsible for the payment of their own premiums. Any premiums exceeding $350.00 per month will result in a reduction of medical deductible/copay assistance – Example: Client premium $375 per month. Part B allows $350 per month. Client difference is $25. $25 x 12 months = $300. Part B allows up to $3000 per year for medical copay/deductibles. $3000 - $300 client responsibility = $2700 balance for client to use on copayments and deductibles.

14. Health and Wellness for all Arizonans azdhs.gov RWPB Contractor Assistance for Clients Contractors may assist Medicare, private and employer based insured clients with their medical copayments and deductibles up to $3,000 per year. – Must be paid using Health Insurance Premium and Cost Sharing Assistance (HIPCSA) funding – Must ensure date of service within the current grant year. (April 1 through March 31) Contractors may assist Medicare clients with Medicare Supplemental insurance premiums. Contractors may ONLY use HIPCSA funds to pay medication copays for clients enrolled in AHCCCS with nominal copays or clients who are not ADAP eligible.

15. Health and Wellness for all Arizonans azdhs.gov Southern Arizona AIDS Foundation (SAAF) Medical Benefits Manager (MBM) The role of the Ryan White Part B Medical Benefits Manager (MBM), Southern Arizona AIDS Foundation, (SAAF), is: To facilitate the payment of FFM premiums for ADAP eligible clients statewide, after they: – Ensure the APTC has been applied in advance prior to paying FFM premiums for “silver level” health plans – Ensure client is ADAP eligible prior to paying FFM premium To facilitate the payments of medical copayments and deductibles for RWPB FFM clients only, after they: – Ensure date of service on invoice is within the current grant year – Ensure the service is allowable under Ryan White

16. Health and Wellness for all Arizonans azdhs.gov HRSA PCN #14-01 –APTC Overpayment In response to HRSA PCN #14-01 ADAP developed and implemented an affidavit for all FFM clients that explained the procedure for identification and submission of APTC overpayment – Mandatory submission of Federal Income Tax, including Form 8962, for all FFM enrollees beginning April 15, 2015 as proof of income (POI) – Clients that did not file must submit an approved IRS extension request – Clients exempt from filing must submit an approved IRS exemption notice – ADAP/FFM enrollee placed on PCD until April 15, 2015 pending ADAP receipt of the affidavit or IRS extension request – Potential for loss of ADAP coverage – Affidavit is part of all FFM enrollees initial or birthday renewal yearly

17. Health and Wellness for all Arizonans azdhs.gov AHCCCS Nominal Copay Assistance The Ryan White Part B Program now assists all Ryan White eligible/active clients with their nominal AHCCCS medication copays effective May 1, 2014. Thanks to an agreement with Avella Specialty Pharmacy, all eligible/active clients who choose to fill their prescriptions with Avella will no longer have the nominal AHCCCS medication copayment. If your clients are interested; 1) please make sure they are showing eligible/active with Ryan White; 2) have the client contact an Avella Specialty Pharmacy at one of the locations listed below; 3) and let the pharmacy know s/he wants to participate in this program: Phoenix (Central Ave.) 1101 N. Central Ave. Ste. 102 Phoenix, AZ 85004 Ph: (602) 257-1133 Fax: (602) 257-1134 Tucson National Distribution Facility 4512 E. Camp Lowell Dr. Toll-free phone: (877) 546-5779 Tucson, AZ 85712 Toll-free fax: (877) 546-5780 Ph: (520) 918-0044 Fax: (520) 918-0043 ** The Ryan White Part B Program has sent a letter to all clients in the statewide CAREWare system that we show have transitioned to AHCCCS informing them of this available program.

18. Health and Wellness for all Arizonans azdhs.gov Questions??