How to Know If You are Eligible for ADAP to Pay for HIV Prescription Drugs

While access to healthcare has increased for people living with HIV since the enactment of the Affordable Care Act (ACA) in 2014, the cost of HIV drugs remains a major challenge. Even for some able to obtain private insurance, the price has become increasingly prohibitive, with some insurers moving antiretroviral drugs from more affordable "generic" and "non-generic" drug tiers to higher priced "specialty" drug tiers that command co-payments of 30% or more.

This practice of adverse tiering has affected both low- and middle-income earners, with many forced to pay for their drugs out of pocket. For a standard three-drug regimen, this could add up to well in excess of $1,000 per month, a price that most would consider unaffordable.

The AIDS Drug Assistance Program (ADAP) is a federal program first established in 1987 to provide lifesaving HIV drugs to low-income Americans. Since that time the scope of the program has expanded considerably, with some states able to subsidize doctor visits, lab tests, insurance deductibles, and even preventive therapy for those at risk of infection.

Eligibility is typically income-based, ranging from households whose annual income is less than 200% of the Federal Poverty Level (FPL) to those whose income is less than 500%. Income calculations are based not on you or your family's total earnings for the year but on your modified annual gross income (essentially the Adjusted Gross Income found on line 37 of your 1040 tax return plus a few add-backs).

This means that, in the 11 states where the income threshold has been set at 500%, a married couple with a Modified Annual Gross income of $80,000 would still be eligible for ADAP assistance.

ADAP Eligibility by State

That's not to say that all ADAP programs are created equal. While ADAP is funded by the federal government, each state administer its own program, sets its own inclusion criteria, and outlines which services it will and will not provide. In some states, that translates to direct prescription drug assistance; In others, services may include regular doctor visits, case management, or (as in New York State) a provision for home-based care.

Although the rules vary from state to state, eligibility is typically based on three factors:

• Documentation of residence within that state. For non-U.S. citizens, documentation of permanent residence is required. Meanwhile, in other states, like New Mexico and Massachusetts, undocumented immigrants are also qualified for ADAP services.
• Proof of income. This is typically based on you or your family's modified annual gross income (MAGI) but can also include a dollar value limitation on our personal assets (as in states like Delaware, Georgia, and New York).
• Confirmation of your HIV status by a qualified physician. In some states, like Arkansas, CD4 count and viral load tests may be used to qualify eligibility.

As ADAP is considered a "last resort" payer, you may still be required to get health insurance even if ADAP services are rendered. In such case, you would need to provide proof of insurance in order to establish need, whether it be for drug coverage, co-pay assistance, or (in some states) deductible or premium payment assistance.

For those unable to obtain ADAP approval, co-pay and payment assistance programs (PAP) are offered by most HIV drug companies to provide free or low-cost medications to those who cannot afford them.