AEGiS-ATDN: Treatment Access Denied

Important note: Information in this article was accurate in 2003. The state of the art may have changed since the publication date.

Treatment Access Denied

Information Bulletin #17 - February 2003

This letter was sent out to everyone on ADAP in New York State. Changes take effect February 15, 2003. At press time, things may seem to have improved, but a strong outcry of outrage is needed by members of the community. Contact you local, state and federal representatives and let them know how you feel. Do it now, because they're already talking about making big changes in Medicaid.

"We are sorry that we have to limit these services, but ADAP must adjust services to match available funding. We strongly encourage you to look for other health care coverage options such as public entitlement programs that cover more drugs and services than ADAP. These include Medicaid, Medicaid Spenddown, Family Health Plus and Veterans Benefits. If you are eligible and enroll in these programs, you will have better coverage. You should also make sure that if you have insurance through your job that you take advantage of this better coverage. The ADAP hotline staff are available (1-800-542-2437) Monday to Friday 8:00 AM to 5:00 PM to answer questions about the Program.

The Uninsured Care Programs (ADAP) has grown rapidly since 1996, with increasing enrollment, higher numbers of participants using the program services, and increasing drug prices. The Program is primarily funded with federal money. To make the best use of limited resources available, we must take steps to make sure that the Program is cost-effective and meets the highest priority needs. The Uninsured Care Programs (ADAP) is making some changes that will allow us to continue new enrollments and maintain core services.

Mandatory Generics - ADAP will stop paying for brand-name drugs when there is a generic equivalent for a brand-name drug. If you have a prescription for a brand-name drug that your doctor has written as Dispense as Written (DAW), you will need to get a new prescription. Please refer to the list enclosed with this letter and share it with your doctor the next time you have an appointment.

Maximum limit of 5 refills per prescription - ADAP will pay for the first prescription and then five (5) refills, then your doctor must write a new prescription. We are making this limit to reduce waste if the doctor changes your medications. You can also help ADAP save money by not refilling prescriptions your doctor has decided that you should stop taking.

New limit on nutritional supplements - The maximum amount of nutritional supplements that ADAP will pay for will be no more than three (3) cans per day or the equivalent in other forms (e.g., powders, bars).

Maximum number of clinic visits each year - ADAP will pay for up to thirty (30) clinic visits each year. Some types of visits to your clinic (that have their own limits) are not included in these limited 30 visits (e.g., annual comprehensive exam, mental health visits, dental visits).

Maximum number of dental visits - ADAP will pay for no more than eight dental (8) visits per year.

Formulary Reduced - ADAP will no longer pay for Famciclovir, Oxandrolone, Androgel, Famotidine (Pepcid), Nizatidine (Axid), Loratidine (Claritin), or Octreotide. If you are taking one of these drugs you should see your doctor to have an alternative drug prescribed.

Quantity Restrictions on Zolpidem (Ambien) - ADAP will pay for only 15 tablets of Ambien per month.

Prior Approval for atovaquone (Mepron) - Your doctor will need to fill a form and send it to ADAP for approval before ADAP will pay for atovaquone (Mepron). If you are currently taking atovaquone, ADAP will mail you a letter with a form for you to take to your doctor "

Why is ADAP so troubled? ADAP funds have to be approved every year by the federal government, and often the state that you live in. The Director of The Network's national program, The Access Project, Lei Chou, wrote a description of the whole ADAP process, and what is going on.

The piece is available at our web site at http://www.atdn.org/crisis.html where you can read it online, or download the PDF and distribute it to anyone you like. Check our website for updates.

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