Making Your Job Easier

To qualify for the Arizona ADAP Assist program:
Upon request, ADAP applicants must provide:

• Documentation of a HIV diagnosis from a Medical Provider with recent viral load and/or CD4 lab values and the current prescribed medication regimen
• Documentation showing the modified adjusted gross income (MAGI) does not exceed 400% of federal poverty level (FPL);
• Documentation showing the applicant is a resident of Arizona;
• Documentation showing the applicant has access to affordable and adequate insurance coverage (including prescription coverage) through a primary insurer such as Medicare, Marketplace, or Employer-sponsored insurance.

• Once ADAP receives an application for an applicant who appears eligible for insurance or is enrolled with coverage, ADAP will request premium, formulary and co-pay information. This information is used to determine if the insurance coverage is adequate and affordable. Adequate means the insurance will cover prescribed antiretroviral (ARV) drug therapy. Affordable is determined by adding the yearly premium primary insurer and calculating if this amount is less than 9.5% of the applicant’s annual MAGI. If the total premium amount is less than 9.5% of the applicant’s annual MAGI, the insurance is affordable and the client must enroll as soon as possible or maintain their coverage. If the total premium amount is greater than 9.5% of the applicant’s annual MAGI, the insurance is deemed unaffordable and the client will be provided other options for insurance coverage including ADAP 340B and/or the marketplace.

The applicant cannot be eligible for AHCCCS (Arizona’s version of Medicaid):

• To ensure that Ryan White Part B is the payer of last resort for ADAP, all applicants for ADAP with a MAGI less than 150% FPL will be screened for AHCCCS eligibility. After the AHCCCS screening occurs, the AHCCCS denial letter must be submitted for review.

ADAP Assist provides copayment assistance for current ADAP Assist clients’ medications that are covered by their private insurance, employer based insurance, Medicare or Federally Facilitated Marketplace (FFM). If the drug is not covered by the member's primary insurance, please refer to the ADAP public website at www.azadap.org for directions on our off-formulary coverage procedure.

ADAP Assist cannot pay copays for the following medication categories:

1. Certain non-FDA approved Over The Counter (OTCs) Medications
2. Erectile Dysfunction (ED)
3. Fertility Agents
4. Non-oral Contraceptives
5. Skin Coloring Agents
6. Retinoids (Retin-A, Differin, Accutane, Others)
7. Hydroquinone (Eldoquin, Others)
8. Prescriptions used for cosmetic purposes
9. Ancillary supplies

Please refer to Ramsell for assistance with the FDA-approved OTCs that are covered. Ramsell Pharmacy Service Representatives are available by calling 1-888-311-7632.

Click on the link below to download a Prior Authorization Form or User Guidelines.

•	Egrifta Application Form
•	Serostim Application Form
•	Sunlenca Application Form

Patients can fill their prescriptions through any participating pharmacy in BOTH their primary insurance pharmacy network AND the Ramsell's pharmacy network.

To locate the pharmacy closest to you, enter your City, Zip code or County in the Ramsell Pharmacy Locator or call Ramsell at 1-888-311-7632.

Contact the ADAP Assist Client Services at (800) 838-9195 or (602) 364-3610 for more information or feel free to visit our website at www.azadap.org.

Unfortunately, because of potential for HRSA OPA 340B duplicate discounts a.k.a. "double dipping," any pharmacy identified as a 340B Covered Entity Pharmacy will not be permitted to join the Arizona ADAP Assist Ramsell pharmacy network.