Making Your Job Easier

• Prescription medications - program pays for certain HIV-related prescription medications. For clients with insurance, this program may pay what insurance doesn't for formulary covered medications.
• Clients receive a client identification number and a pharmacy card. They can present one of these to a contracting pharmacy to get their medications, in most cases for a nominal monthly fee.
• Washington State Early Intervention Program also provides assistance in medical services, as well as in acquiring insurance and Medicaid eligibility.

Please call 1-877-376-9316 or visit Washington State Department of Health for more information about how to apply.

Basic requirements for all Washington State Department of Health Prescription Drug Program applicants:

• Are HIV positive
• Live in Washington State
• Have a gross monthly income of $2,553 (in 2007) or less as a single person. Applicants to the program prior to September 1, 2002 may have incomes up to $3,149.
• Have financial resources of $10,000 or less (not counting one home, one automobile and certain retirement accounts).

Additional requirements for applicants with Medicare:

• Applicants with Medicare must be enrolled in a Prescription Drug Plan (PDP) or insurance that is "as good as" a PDP. If the applicant isn't enrolled in a PDP or "as good as" insurance, the applicant will receive temporary eligibility while enrolling.
• Applicants with a PDP and a gross monthly income at or below $1277 for a single person, must apply for Extra Help (also known as Low Income Subsidy) with Social Security Administration. Applicants will receive temporary eligibility during the Extra Help application period.

There are additional requirements for some applicants who may be eligible for Medicaid.

• Proof of residency
• Proof of income OR signature on a "no income" declaration statement
• A copy of your client's Medicare card (if applicable)
• A copy of insurance credibility statement or copy of a PDP or MA-PD card
• A copy of your client's insurance card (if applicable)
• Signed HIV medical documentation (new applicants only)

Please click on the links below to download a PDF with a complete list of medications on Washington State AIDS Drug Assistance Program (EIP) formulary.

•   Formulary for clients in Groups 1 and 3
•   Formulary for clients in Group 2

Patients can fill their prescriptions through any one of the participating pharmacies in Washington.

To locate the pharmacy closest to your patient, enter their zip code or city in the form to the right, or call Ramsell at 1-888-311-7632.

Patients have the right to apply, to appeal decisions and to receive confidential, nondiscriminatory, courteous and respectful service.

If you believe a client has been denied their rights, or treated unfairly or discourteously at any point in the enrollment process, or while receiving pharmacy services, you may contact the local coordinator for your county or the Washington State Department of Health at 1-877-376-9316.

Fuzeon

Authorization to receive Fuzeon is given in six-month periods and access to Fuzeon is limited based on the availability of openings.

Please be sure to include any necessary lab measurements that show the patient's viral load measurement, CD4 count and genotype resistance profile. Download PDF

Aptivus

Please make sure to fill out EITHER section 1 OR 2 of the application.
Download PDF

Pegylated Interferon

Patients must submit a request for pegylated interferon thru the WA Washington State Department of Health Prescription Drug Program by first submitting this form to Ramsell. Download PDF

Baraclude

Patients must fail therapy with both lamivudine and tenofovir prior to therapy with Baraclude. There must be documented treatment failure evidenced by a (+) Hep B DNA and a (+) Hep BeAg (Hep B envelope antigen). Download PDF

Anabolic Steroids

Please fill out Form A for the initial approval only and Form B for subsequent refill requests.

Please be sure to include documented dates and dosage of testosterone therapy when applying for the initial approval. Download PDF

Maraviroc (Selzentry™)

Maraviroc is approved for patients with CCR5 mono-tropic HIV confirmed by tropism assay results. Please fill out the maraviroc prior authorization form.

Trofile™ test showing "CCR5 only" is required for maraviroc new starts. It is not required for those already on maraviroc through clinical trials, expanded access or other insurance.

The Selzentry (maraviroc) prior authorization access form must be faxed back to the program Pharmacy Benefit Manager, Ramsell at 800-848-4241. Download PDF