Important note: Information in this article was accurate in December 2002. The state of the art may have changed since the publication date.
Treatment Issues: Newsletter of Experimental AIDS Therapies - Volume 16, Number 12, December 2002
The following is the text of a letter being sent to health care providers in New York State concerning the first wave of cutbacks to New York State's AIDS Drug Assistance Program (ADAP).
New York State's Uninsured Care Programs (ADAP) has grown rapidly since 1996, with increasing enrollment, higher numbers of participants using 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. The following changes are effective February 15, 2003.
Mandatory Generics — ADAP will stop paying for brand-name drugs when there is an A-rated generic equivalent for a brand-name drug. If you get a prescription that is Dispense as Written (DAW), the participant will need to get a new prescription. There will be no exception process for these medications (see the list of affected medications enclosed with this mailing).
Maximum limit of 5 refills per prescription — ADAP will pay for the first prescription and then five (5) refills. This step will help ADAP reduce waste and save money by not refilling prescriptions that have been discontinued. To assure that funding is maximized for all participants, pharmacies should not automatically refill and bill for medications without assurances from the participant that they are still taking the medication.
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 amount in other forms (e.g., powders, bars).
Maximum number of clinic visits each year — ADAP will pay for up to thirty (30) clinic/threshold visits each year. Enhanced fee visits (that have their own limits) are not counted toward this 30-visit limit (e.g., annual comprehensive exam, mental health visits and dental visits).
Maximum number of dental visits — ADAP will pay for no more than eight (8) dental visits per year.
Formulary Reduced — ADAP will no longer pay for the following drugs.
Quantity Restrictions on Zolpidem (Ambien) — ADAP will pay for only 15 tablets of Ambien per month.
Prior Approval for atovaquone (Mepron) — ADAP will require prior authorization through a physician to pay for atovaquone (Mepron). Participants currently taking atovaquone will receive a separate letter with the authorization form to bring to their doctors.
We are sorry that we have to limit these services, but ADAP only has the funds allocated to it each year and must adjust our services to match our funding.
Please assist our participants in securing 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 Health Care Coverage. These programs offer more comprehensive coverage.
As always, the New York State ADAP hotline staff are available (1-800-542-2437) Monday to Friday 8:00 a.m. to 5:00 p.m. to answer questions about the Program.
State ADAPs with waiting lists, client expenditure caps and/or drug access restrictions:
Alabama — 175 people waiting
Guam — 4 people waiting
Idaho — Program closed to new enrollees
Indiana — 4 people waiting
Kentucky — 62 people waiting
Montana — 2 people waiting
Nebraska — Program closed to new enrollees
North Carolina — 60 people waiting
Oregon — 18 people waiting
Puerto Rico — 64 people waiting
South Dakota — 43 people waiting
Texas — ARV restrictions
Wyoming — Program closed to new enrollees
Washington — Program restrictions
Source: www.ATDN.org
Message to Congress: SAVE ADAP!
Dear Senator/Representative:
The undersigned organizations serving the needs of people living with HIV write to ask that Congress provide a minimum of $162 million in additional federal funding for AIDS Drug Assistance Programs for FY 2003.
This year, 13 state AIDS Drug Assistance Programs (ADAPs) have been forced to take steps to limit access to life-saving HIV medications for uninsured and underinsured Americans due to inadequate funding. Texas, for example, has recently announced that in order to close its deficit, it will retroactively lower its income limits from 200% of the federal poverty level (300% with spend downs) to 140%. That action will require the removal of 2500 presently enrolled ADAP clients from the program by June 1, 2003.
New York must also address a $16 million structural deficit in 2003 and a projected $50 million deficit in 2004 if either state/and or federal funding is not increased by that amount.
According to the most recent National Alliance of State and Territorial AIDS Director's (NASTAD) Report, the following states have also initiated waiting lists as of 12/5/2002: Alabama (175), Indiana (34), Kentucky (62), Montana (2), North Carolina (60), Oregon (18) and South Dakota (43). Idaho, Nebraska and Wyoming have closed to new enrollees. In addition to New York and Texas, Colorado, Florida, Georgia, Nevada and South Carolina have projected the need to impose access restrictions in early 2003.
One major factor driving increased ADAP need is enrollment growth, which is due to the success of the new drugs in decreasing deaths and slowing progression to AIDS. Since the introduction of effective combination HIV therapies in 1996, America's death rate from AIDS has fallen by over 50%. Because people are staying alive longer, they need ADAP longer and so enrollment continues to climb. While this should be taken as a sign of the program's success, resources flowing to ADAPs are not being increased to take care of the swelling numbers of people that are being kept alive.
Ironically, attempting to save money in the short term may cost taxpayers more money in the long term. Recent data presented by the University of Alabama at Birmingham at the International AIDS Conference in Barcelona demonstrates that the average cost of care for a person with early HIV disease is approximately $14,000 a year while waiting to treat that person until they are disabled costs about $34,000 a year.
Fears of particularly serious problems for FY 2003 are exacerbated by the expected arrival of new drugs that few programs in crisis are likely to be able to afford. Fuzeon (T-20), the first fusion inhibitor to reach the market, could provide urgently needed support for patients whose anti-retroviral options have run out when it is approved in early 2003, but the drug is expected to be expensive, which could force ADAPs to ignore the need for the drug.
The second class of drugs that most ADAPs are unlikely to be able to afford are those to treat HCV. While HCV has become the number one cause of death among people with HIV, most states are resistant to adding new classes of treatment when resources are scarce.
Finally, in order to make best use of ADAP funding we ask that you fund required services provided under the Ryan White CARE Act at the highest possible levels. Without the support services provided by the CARE act, many ADAP clients would have no realistic access to the medical care and auxiliary services they require to maximize the usefulness of anti-HIV medical regimens.
We believe that it is imperative to provide life-extending AIDS drugs to all Americans in need. We hope that you will agree.
Sincerely,
Partial listing: ADAP Working Group
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