Most of the programs that offer prescription drug coverage are described in detail elsewhere on DB101. Below, you’ll find brief descriptions of these programs, along with information on Patient Assistance Programs PAPs, and a detailed program description of the AIDS Drug Assistance Program (ADAP).

Private Health Coverage

Most Private Health Coverage plans have some sort of prescription drug coverage. You or your employer pay a monthly premium to be enrolled in a plan. When you get medical services, the plan will help you pay for the costs of those services that it has agreed to cover. Depending on the specifics of your plan, prescription drugs may be one of those services. You may have to pay a certain amount of money before your plan will help you pay. This is known as a deductible. After you’ve paid your deductible, you may have to pay each time you buy drugs. You may pay a small fee, called a copayment, for every prescription you buy. Other plans may require that you pay a certain percentage, called coinsurance, of the cost of each drug. Every plan will be different. Some may not cover prescription drugs at all. Check the specifics of your plan to see what is covered under which circumstances. DB101’s Private Health Coverage section has more information on enrollment, rules, and other general information on Private Health Coverage.

Medi-Cal

Medi-Cal is a program that offers health coverage to people with low income who are over 65, blind, or disabled. Medi-Cal is California’s Medicaid program. It usually comes with extensive prescription drug coverage. Depending on your situation, this coverage can be free, cost a small premium, or require that you spend a certain amount of your own money before coverage begins. DB101’s section on Medi-Cal has detailed information on common ways to enroll in the program, along with information about how the benefit works.

Medicare

In 2003, Medicare added prescription drug coverage. It previously only offered hospital (Part A) and outpatient (Part B) coverage. The new prescription drug benefit is called Medicare Part D. Private companies manage Part D prescription drug plans while the government determines eligibility and enforces program rules. You generally have to pay premiums, deductibles, and copayments or coinsurance, but there is help available for many of those who can’t afford these costs. There are also special rules about people who are eligible for both Medi-Cal and Medicare. DB101’s Medicare Part D section has extensive information on Part D.

Patient Assistance Programs (PAPs)

Private drug companies offer programs that help low income people afford prescription drugs. Each PAP has its own rules about eligibility and what they will pay for. Many of these companies are part of a group called Pharma. You can search a directory of PAPs offered by Pharma members. You will have to have information about your income and drug needs in order to find a PAP that meets your needs. The DB101 resources section on PAPs also lists other websites that have guides to PAPs. For more information on PAPs, go to one of those websites or see DB101’s FAQ on Patient Assistance Programs.

AIDS Drug Assistance Program: ADAP

People with HIV/AIDS generally need to take a lot of prescription drugs. Many of these drugs are expensive. Some people get help paying for them through private or public health coverage programs. But some people aren’t on those programs and even those who are sometimes still have drug costs beyond what their health coverage will pay for. There’s a program called the AIDS Drug Assistance Program (ADAP) that helps people with HIV/AIDS pay for the costs of some prescription drugs.

How ADAP Works

ADAP is what is called a payer of last resort. That means that you have to apply for all other programs that might help pay drug costs and use those programs before ADAP will help pay.

If you are on other insurance, ADAP can help pay for drugs that aren’t covered by that plan, or for the portion of the cost that you would normally have to pay out of pocket. You may, for example, have to pay a deductible, which is a certain amount of money you have to pay before insurance will start helping with your costs. You also may have to pay a small fee, called a copayment, for each drug you buy, or a certain percentage, called coinsurance, of the cost of the drug.

ADAP only covers drugs for HIV/AIDS and related conditions. There’s a list of drugs that ADAP will help pay for. This list, like similar lists from other health coverage programs, is called a formulary. ADAP’s formulary has more than 150 drugs on it. To get ADAP to help pay for drugs, you have to go to one of the 3,500 participating pharmacies in California.

Eligibility and Enrollment

ADAP is coordinated by the Office of AIDS in the California Department of Public Health. They use an organization called the Public Health Service Bureau to run the program. The Public Health Service Bureau has an excellent website describing the program and explaining how to apply. To be eligible for ADAP, you have to meet all of the following requirements:

• Be HIV positive,
• Be a California resident,
• Be over 18,
• Have federal adjusted gross income less than $50,000 a year,
• Have a prescription from a California doctor,
• Have limited or no prescription drug coverage, and
• Not qualify for no-cost Medi-Cal

You find your adjusted gross income by looking at your tax returns. You can request a copy of them from the IRS.

If ADAP is paying for a drug and you have income over 400% of the Federal Poverty Level (FPL), you’ll have a copayment when you buy a drug on ADAP’s formulary. This means that you’ll pay a small fee for each prescription that you fill. If you have less than 400% of FPL, the drug will be free.

To enroll in ADAP, go to one of the 250 enrollment sites in California. You’ll need to bring the following documents with you when you enroll:

• Proof of residence (like a utility bill),
• Photo ID,
• Verification of Income (like tax returns, pay stubs, or benefit award letters),
• Applications to Medi-Cal or private health coverage, and
• A letter of HIV diagnosis from within the past 6 months.

Interaction with Medicare and Medi-Cal

If you are on Medicare Part D and ADAP, ADAP is still the payer of last resort. To stay eligible for ADAP, you must enroll in Medicare Part D if you are eligible. You should make sure you go to a pharmacy that participates in your Part D plan as well as ADAP. In general, Part D plans will pay for most of your HIV/AIDS drugs. This is because antiretrovirals are one of the categories of drugs that Part D plans must cover fully. You have to apply for Part D’s Low Income Subsidy before ADAP will pay. ADAP pays for copayments, deductibles, coinsurance, and costs during the donut hole. It does not pay for Part D premiums. The Office of AIDS has a helpful FAQ on ADAP and Part D that provides further details.

If you are Medically Needy Medi-Cal with a Share of Cost (SOC), that means that you have to spend a certain amount of money each month before Medi-Cal starts to pay. The money spent on drugs that are paid for through ADAP can count towards your SOC. If you’re on Medi-Cal and Medicare Part D, it will be difficult to spend down your SOC because the only drugs that aren’t covered by either Part D or Medi-Cal are Xanax and Atavan.

Sources:

The Office of AIDS in the California Department of Public Health is responsible for ADAP. They have a website with general information on the program.

The Public Health Service Bureau runs ADAP in California. Their website describes the program and has information on enrollment, formulary, and participating pharmacies.