Nevada Ryan White CARES Act grantees enrolled in 340B are strongly protesting a state AIDS Drug Assistance Program (ADAP) policy change that the clinics say will deprive them of 340B savings on drugs that pay for housing, transportation, and other wrap-around services for patients living with HIV.
The state’s ADAP is called the Nevada Medication Assistance Program (NMAP). It provides low-income patients living with HIV with health insurance that includes pharmacy benefits. NMAP also covers these patients’ drug co-pays and deductibles and contributes to their Medicare Part D out-of-pocket costs.
Under the policy change, due to take effect Jan. 18, Ryan White clinics and other 340B covered entities participating in NMAP’s pharmacy network must agree not to dispense 340B-purchased drugs to NMAP clients. Some NMAP documents about the policy change appear to indicate this is a blanket prohibition. Other documents, however, appear to indicate that, once an NMAP-client “reaches out-of-pocket maximum,” a Ryan White clinic can dispense 340B-purchased drugs to the patient and “generate program income as an indirect benefit.”
NMAP said in one of the documents describing its new policy:
All 340B covered entities will have the choice of not participating in the NMAP pharmacy network. If that entity chooses not to participate in NMAP’s pharmacy network and the entity is providing 340B pharmacy service(s) to NMAP patients, then the entity will be responsible for all patients cost associated with their HIV care [i.e., health insurance premiums payments, associated cost-share (medical and pharmacy), core medical and supportive services].
State ADAPs are unique among 340B covered entities in that they alone can choose to receive the benefit of reduced 340B pricing either as an up-front discount or as a back-end rebate. ADAP rebates are available only on drugs not purchased at 340B prices.
If a Nevada 340B-eligible covered entity dispenses drugs to a patient with prescription drug coverage paid for by NMAP, NMAP cannot seek a 340B rebate on the claim, due to the statutory prohibition on 340B duplicate discounts. In effect, NMAP’s new policy requires 340B covered entities to “carve out” 340B for NMAP clients so NMAP can get the rebates. The state has said it needs the 340B rebate revenue to enable it to meet federal Ryan White program matching grant requirements. The state says its match requirement has grown due to an increase in clinics enrolling in the Ryan White program.
AIDS Healthcare Foundation (AHF), which operates 340B-enrolled Ryan White clinics in Las Vegas and North Las Vegas, is leading the opposition to NMAP’s new policy.
Patricia Bermudez, AHF senior regional director, recently told The Nevada Independent news and opinion website that NMAP’s policy could force AHF’s two Nevada clinics to shrink their geographic service boundaries or to cut services.
“Not having that margin for 340B puts us in a really big bind because, one, we’re limited. We will have limited resources to help community partners and then limited resources to expand our services for our patients,” Bermudez said. “That’s really the impact across the board.”
AHF has organized a Twitter storm to persuade Nevada Gov. Steve Sisolak (D) and state lawmakers to stop NMAP from implementing its new 340B policy.