Getting Patients the Help
They Need

To qualify for ADAP Assist clients must be HIV-infected, a resident of Arizona, not eligible for AHCCCS (Arizona's version of Medicaid) and have an annual income at or below 300% of federal poverty level (FPL).When we receive an ADAP application for a client who is insured or eligible for insurance, we ask for premium, formulary and co-pay information. ADAP needs this information to determine whether the coverage is adequate and affordable. Adequate means the insurance will cover the antiretroviral (ARV) drug therapy. Affordability is determined by adding the yearly premium and co-pays and comparing the total to the Health Resources and Services Administration (HRSA) affordability guidelines (see below). If the client's premium and co-pays for the year are more than 5 or 7% of their income, then the insurance is deemed unaffordable and the client is enrolled in ADAP Assist. If premium and co-pays are affordable, then the client will not be eligible for ADAP Assist.

• 100-199% Federal Poverty Level (FPL) = 5% of annual income = affordability
• 200-300% FPL = 7% of annual income = affordability

There is no set formulary for Arizona ADAP Assist. Arizona ADAP Assist honors the primary insurance's formulary and pays the member's copayment obligation. If the drug is not covered by the member's primary insurance, Arizona ADAP Assist will not cover the prescription.
ADAP Assist will not cover the following types of medication:

1. 1. Contraception medicines or devices like birth control pills
2. 2. Drugs for treatment of Erectile Dysfunction
3. 3. Prescriptions used for cosmetic purposes
4. 4. Fertility Agents

Click on the link below to download a Prior Authorization Form

•	Application for Patient Access to Fuzeon
•	Guidelines For the Use of Enfuvirtide (Fuzeon)
•	Enfuvirtide (ENF, Fuzeon) Application
•	Valganciclovir Use Guidelines
•	Valganciclovir Application
•	Pregabalin (Lyrica) Use Criteria and Application
•	Egrifta Application

Patients may continue to use Avella Specialty Pharmacy (formerly The Apothecary Shops) at (866) 881-4902 or www.avella.com each time you need a refill. Prescriptions can also be filled through any one of the participating pharmacies. To locate the pharmacy closest to you, click on the document below.

> List of Pharmacies

Or call Ramsell at 1-888-311-7632.

Contact the Arizona ADAP Client Services at 602-364-3610 for more information about the program or visit our website. http://www.azdhs.gov/phs/hvstdhpc/adap.htm