First Wave of Cuts Hits New York's ADAP
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
Back to the GMHC Treatment Issues December 2002 contents page.