Making Your Job Easier

HealthPAC under the new process for the Low Income Health Program (LIHP) will provide federal support for low-income people living in Alameda County who meet certain federal requirements and income guidelines. The Health Program of Alameda County HIV Program provides prescription coverage for certain HIV and HIV related prescription medications to HealthPAC MCE and HealthPAC HCCI participants. Participants who are enrolled in the program must go to an approved pharmacy designated by their HealthPAC medical home.

Participants will receive a HealthPAC MCE or HealthPAC HCCI card.

HealthPAC has three categories of members based on income, ability to meet Deficit Reduction Act (DRA) requirements, and other coverage. Health Care Reform will change HealthPAC in January 2014.

• HealthPAC MCE
  Medi-Cal Coverage Expansion (MCE) members will be eligible for Medi-Cal in January 2014. This is an LIHP category
• HealthPAC HCCI
  Health Care Coverage Initiative (HCCI) members will be eligible for the Health Exchange in January 2014.This is an LIHP category
• HealthPAC County
  "County" members stay in the County program. This is not an LIHP category.

Participants may be eligible for HealthPAC MCE or HealthPAC HCCI if:

• You are an Alameda County resident AND
• You are a U.S. citizen or have been a legal permanent resident for at least five years AND
• You are age 19 to 64 AND
• Your income is 0-200% (up to $1,862 per month for a single person) of the Federal Poverty Level AND
• You are not eligible for, or enrolled in Medi-Cal AND
• You aren't pregnant

To learn more about HealthPAC, click here!

Please click the links below to download a PDF with a complete list of medications.

•   Formulary listed Alphabetically
•   Formulary listed by Drug Class

Participants who are enrolled in the program must go to an approved pharmacy designated by their HealthPAC medical home.

> Click here to find a complete list of Free or Low-cost Doctor/Clinic in Alameda County

Health Care Services Agency / HealthPAC (HCSA) has an established mechanism for reviewing and processing requests for pharmaceutical services that require prior authorization.

The pharmacy or medical provider must complete the prior authorization form and fax to: (510) 351-1367.
Please call (510) 618-3452 for questions about the prior authorization approval process.

Fuzeon (Enfuvirtide)

When completing Fuzeon access forms, please be sure to include all requested clinical information including CD4 lab measurements as well as two viral load measurements. If your patient has never used Fuzeon, please submit TWO detectable viral load measurements within the last six-months in order to provide medical justification for starting Fuzeon. If your patient has received Fuzeon previously through another insurance payer (e.g. Medi-Cal, Medicare Part D, private insurance), you must provide TWO detectable viral load measurements within a six-month period prior to the date the patient started Fuzeon treatment.
Download PDF

---

Maraviroc (Selzentry™)

Maraviroc is approved for patients with CCR5 mono-tropic HIV confirmed by tropism assay results. Please fill out either section 2 OR section 3, whichever is applicable to your patient.
Download PDF

---

Rosiglitazone (Avandia™)

When completing rosiglitazone (Avandia™) access forms, fill out section 2 of the application completely if your patient is an existing HealthPAC HIV client who is newly initiating rosiglitazone or is a HealthPAC HIV client who previously received rosiglitazone through another payer (i.e. Medi-Cal, Medicare Part D or Private Payer). Fill out section 3 of the application completely if your patient is currently taking rosiglitazone or continuing treatment. Download a copy of the access form and submit the form prior to dispensing rosiglitazone. Please be sure to include all requested clinical information including a signed informed consent form and a list of therapies that have been tried and failed.
Download PDF

---

Serostim

Please be sure to fill out Form A, section 1 of the application completely if your patient is a new-start applicant or is receiving Serostim through another payer source. If you are requesting a refill of Serostim beyond the initial 3-month approval please fill out Form B.
Download PDF

---

Zyvox

Zyvox™ requires a prior authorization and is only covered for the treatment of Vancomycin resistant MRSA or Extensively Drug Resistant Tuberculosis.
Download PDF

---

Non-Formulary Antiretroviral (ARV) Request Form

The HealthPAC HIV Program does not cover any non-formulary requests other than those for ARVs. For all other requests, please contact the client’s HealthPAC HIV Medical Home.

Please only use this form to request ARVs that are not on the HealthPAC HIV Formulary. The forms will only be reviewed for the following purpose:

• To request non-formulary ARV medication(s) that has a medical justification for patients in the HealthPAC HIV Program

Download PDF

For more information and questions on program enrollment, please contact:

Fanny Funes, PhT
Phone: (510) 383-1790 FAX
Fax: (510) 567-6850
Email: HealthPACquestions@acgov.org
This is not a secure e-mail. Do not put personal health information in the e-mail.
To learn more about HealthPAC, click here!