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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

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north carolina aids drug assistance program adap

North CarolinaAIDS Drug Assistance Program (ADAP)

State Pharmaceutical Assistance Program (SPAP)

what is an 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 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
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 review1
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
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 spap1
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
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
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
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
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
Questions?
  • Sally Kohls: 919-733-9602 or sally.kohls@ncmail.net
  • Robert (Bob) Winstead: 919-715-3115 or robert.winstead@ncmail.net
  • NC ADAP Website http://www.epi.state.nc.us/epi/hiv/adap2.html