Programmatic Challenges and Opportunities

Many ADAPs grappled with a number of program-level challenges in CY2022, including pharmacy network issues, health department staff turnover (33 respondents reported this as somewhat or very challenging, a 29% increase compared with CY2021), ensuring maintenance of client eligibility, timely rebate payments from manufacturers (27 respondents reported this as somewhat or very challenging, a 17% decrease compared with CY2021), and coordination with other 340B covered entities regarding 340B and program income right-of-way determinations to avoid duplicate discounting.

Approximately half of all respondents also reported challenges implementing long-acting injectables and other provider-administered drugs as part of their full-pay medication programs and ADAP-funded insurance programs, which has been an important area of NASTAD technical assistance to state and territorial programs. A number of ADAPs have also expanded their policies and procedures to meet the medical benefit needs of their clients, including coverage of long-acting injectable and other provider-administered antiretroviral drug administration and office visit costs, which are allowable federal dollar expenditures. As of July 1, 2023, 21 ADAPs are covering antiretroviral drug administration costs for their full-pay medication program clients; 26 ADAPs are covered antiretroviral drug administration cost-sharing expenditures for their insured clients. 

To help meet the challenges and complexities associated with pharmacy- and provider-based prescription drug access and insurance service delivery, contractual services provided by pharmacy benefit managers (PBMs), medical benefit managers (MBMs), and insurance benefit administrators (IBAs) have become increasingly important to ADAPs nationally. Of 51 programs providing data, 36 (71%) and 39 (76%) utilize PBM services and 7 (14%) and 10 (20%) utilize MBM services for their full-pay medication programs and ADAP-funded insurance programs, respectively. Twenty-two (43%) programs reported using IBA services to maximize the operations and capacity of their insurance programs.

A potential challenge for many ADAPs is the March 31, 2023, end of the Medicaid continuous coverage requirement, which occurred with the Consolidated Appropriations Act of 2023 being signed into law at the end of CY2022. The continuous coverage provision authorized by the Families First Coronavirus Response Act effectively prohibited states from terminating most Medicaid enrollees’ coverage until after the COVID-19 Public Health Emergency. This allowed millions of people, including PLWHA, to stay covered without any interruption during the pandemic. With the “unwinding” of the continuous coverage requirement – the process by which states have resumed annual Medicaid recertification reviews – a sizeable number of low-income PLWHA were expected to lose their Medicaid coverage beginning April 1, 2023, and, consequently, require immediate enrollment (or re-enrollment) in ADAP. Calendar year 2022 ADAP enrollment (including new enrollment) data collected for the 2024 Annual Report should serve as a benchmark for analyses of Medicaid-unwinding-related ADAP new enrollments/re-enrollments in the 2025 and 2026 Annual Reports that will include CY2023 and CY2025 ADAP enrollment data.

New to this year’s report is a review of ADAPs with active advisory committees. While not required by HRSA HAB, advisory committees are maintained by many ADAPs to leverage stakeholder expertise and lived experiences to ensure these safety nets are meeting the formulary and broader prescription drug access needs of PLWHA in their jurisdictions. As of July 1, 2023, 36 of 51 (71%) ADAPs reporting data had active ADAP advisory committees. Clinicians, pharmacists, and health department staff serve as representatives on more than 80% of the advisory committees, with PLWHA serving as representatives on 70% of the advisory committees. With respect to committee priorities, formulary management is a responsibility for all 36 reported advisory committees, with 24 (67%) providing guidance on utilization management policies and procedures, 13 (36%) advising on quality management issues, and 11 (31%) providing input pertaining to insurance purchasing and coordination.