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The Application Process | Criteria | Obtaining Medications
The Application Process
- The application process was designed to minimize client burden and provide excellent customer care.
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Clients have two options to complete an application: (1) over the phone, with the completed application mailed to client to be returned with a signature and income documentation or (2) complete the entire application by mail and/or fax to the ADAP Central Office.
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When appropriate and approved by the client, ADAP Central Office staff will use identified client advocates (case managers, local ADAP coordinators, social workers) to expedite and assist with the application.
- Once the clients application is complete, ADAP Central Office staff will triage the client to the most appropriate assistance program under ADAP. Programs can include help with medications, insurance payments or Medicare Part D payments.
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Clients will be required to complete a recertification every six months. Every effort will be made to ensure a client’s successful application.
Criteria
Please visit ADAP Updates to view policy memos.
- Eligible applicants must reside in Virginia.
- All client eligibility for ADAP is determined at ADAP Central Office or through Virginia Commonwealth University Health Systems Financial Counseling and Governmental Services.
- Applicants referred to ADAP Central Office will be allowed thirty days (30) to respond to the first attempt by ADAP Central Office to initiate the application process. On the 30th day, if ADAP Central Office has not heard from the applicant, the applicant shall be considered ineligible and the application will be closed. Applicants who do respond to ADAP Central Office will be given a total of sixty (60) days, inclusive of the initial 30, to complete an application. Applicants may reapply at any time.
- CD4 counts and viral loads at time of application (within the last 6 months) must be reported as part of the application process and must be updated every 6 months as part of the recertification process.
- Clients must have no third party insurance coverage for the prescribed medication(s).
- Federal policy gives Veterans (who meet all other ADAP eligibility criteria) the option of accessing covered medications through ADAP.
- The client must be ineligible for Medicaid. If client is referred to Medicaid, verification of application submission must be provided within 14 days of entry into ADAP. The local health department will provide the client with medications through ADAP until Medicaid is approved. To remain eligible for ADAP, clients must submit proof of Medicaid ineligibility within 90 days of Medicaid application. If a client loses Medicaid coverage, medications will again be provided through ADAP.
- Individuals without income must submit either a signed letter of support or evidence of unemployment status. It is not required that this documentation be notarized.
- ADAP eligibility must be recertified every 6 months. Clients are required to report changes in income, insurance or Medicaid status when they occur. Failure to report changes in factors impacting eligibility may result in discontinuation of ADAP services.
- Clients shall be considered ineligible for ADAP after three documented attempts by ADAP Central Office staff to obtain proof of income, insurance or Medicaid status.
- Clients are not required to live in the health district where they receive ADAP.
- HIV-infected pregnant women or newborn infants of HIV-infected mothers are eligible for antiretrovirals regardless of their CD4 count or viral load.
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ADAP and Medicare Part D Eligibility
POLICY ON ADAP-ELIGIBLE CLIENTS WITH MEDICARE PART D
BACKGROUND:
Serving clients through the Medicare Part D Assistance 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.
POLICY:
- Effective immediately, all ADAP-eligible clients who have Medicare Part D must be enrolled in MPAP.
- Clients with Medicare Part D will not be served through the more costly traditional ADAP. If a client with Medicare Part D declines enrollment to MPAP, that client will be disenrolled from all ADAP services.
- ADAP-eligible clients who are also eligible for Medicare will be instructed to obtain a Medicare Part D plan. If a client declines enrollment into a Medicare Part D plan, that client will be disenrolled from all ADAP services. Clients may be supported on ADAP (as funding allows) while applying for a Medicare Part D plan, and may be supported on MPAP while applying for LIS (if indicated).
DOCUMENTATION:
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.
EXCEPTIONS: NONE
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Requirements for the continuation of ADAP medication access:
- Eligible clients will have access to medications covered on the formulary. Such clients will meet all of the above requirements.
- New prescriptions, CD4 and viral load counts are required every 6 months.
Additional ADAP Program Requirements:
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All pregnant women seen at prenatal clinics must be counseled about HIV infection and offered HIV testing. Women testing positive for HIV must be informed they could transmit HIV infection to their newborn baby and about the potential benefits of antiretroviral therapy and other measures in reducing prenatal transmission. They must be informed about the other measures in reducing prenatal transmission. They must also be informed about unknown long-term effects of antiretroviral therapy during pregnancy. The most recent guidelines published for preventing perinatal transmission of HIV can be accessed at www.aidsinfo.nih.gov.
- Periodic site visits to all local health departments will be made by the VDH ADAP Coordinator to assure quality administration of ADAP.
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Obtaining Medications
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Clients will utilize local health departments to drop-off and pick-up prescriptions.
- Medications will be dispensed for clients who have been determined eligible for the program.
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ADAP Central Office staff will communicate with the local ADAP coordinator to ensure medications are ordered for eligible clients; however, valid prescriptions must be provided to the local health department for medications to be dispensed.
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VCH-HS Financial Services will continue to manage ADAP eligibility for clients obtaining ADAP medications through ACC Pharmacy and Hayes Willis.
Application Materials
Coming Soon
- Frequently Asked Questions
- Full Application Overview
Questions or comments?
Medication Eligibility Hotline 1-855-362-0658
