Section 692.10  Drugs to Prolong the Lives of Non-Medicaid Persons with Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV) Infection

Drugs provided under this Section are paid for on behalf of low income individuals with Acquired Immunodeficiency Syndrome (AIDS) or persons with the Human Immunodeficiency Virus (HIV).

a)         To qualify for services under this Section, a person must be enrolled in the AIDS Drug Assistance Program as of June 4, 1996, or:

1)         make application with annual renewal to the Illinois Department of Public Health (Department);

2)         be diagnosed as having AIDS or HIV;

3)         qualify financially with anticipated gross monthly income at or below 400% of the most recent Federal Poverty Guidelines published annually by the U.S. Department of Health and Human Services for the size of the household (see Appendix A);

4)         not be eligible for 80% or greater insurance coverage for drugs through another third party payor;

5)         not be eligible for the Medical Assistance Program (Medicaid) on the date drugs are obtained (individuals with financial/medical assistance applications pending or individuals in spenddown unmet status may participate);

6)         not be eligible for payment for prescription drugs from any other governmental entity; and

7)         be a legal resident of Illinois, as defined by Section 2-10 of the Public Aid Code [305 ILCS 5/2-10], except that:

A)        the provision of Section 2-10 of the Public Aid Code stating that applicants for or recipients of public aid must meet such durational requirements as to residence contained in applicable Sections of the Public Aid Code shall not apply to this Part; and

B)        the provision of Section 2-10 of the Public Aid Code regarding recipients of aid under Article III, IV, or VI [305 ILCS 5/Art. III, IV or VI] shall apply to any recipient of services under the AIDS Drug Assistance Program.

b)         Persons enrolled in the AIDS Drug Assistance Program must reapply annually in order to continue receiving drugs through the Program.

1)         Renewal applications must be received by the Department by the expiration date of the client's current enrollment.

2)         If a renewal application is not received by the Department within 15 days after the expiration date of the client's current enrollment, the client will be removed from the Program and will be required to meet the eligibility requirements of subsections (a)(1) through (7) of this Section in order to continue receiving drugs through the Program.

c)         The Department may suspend a client's enrollment in the AIDS Drug Assistance Program under the following circumstances:

1)         submittal of fraudulent application information by an applicant or client;

2)         failure to submit an application by the due date;

3)         failure to utilize the Program for a six month period.

d)         Subject to the availability of funds the Department may implement cost control measures such as client benefit maximums or limitations on new enrollments.

e)         All drugs provided under the AIDS Drug Assistance Program have been approved by the federal Food and Drug Administration.  The following categories of drugs may be covered under the AIDS Drug Assistance Program.  The Department, with the advice of the medical issues subcommittee of the Title II Ryan White AIDS Advisory Council, will determine which drugs will be covered, based on criteria that include the medical appropriateness of the drug for treatment of HIV/AIDS and associated complications:

            Category I - Drugs for Anti-Retroviral Therapy;

            Category II - Drugs for PCP Prophylaxis and Treatment;

            Category III - Drugs for Prophylaxis and Treatment of Opportunistic Infections and Anti-Microbials;

            Category IV - Drugs for Treatment of Neoplasms; and

            Category V - Other Drugs Requiring Prior Approval.

f)          All prescriptions must be filled by the Department's pharmacy contractors.

g)         The Department may require participants to pay a copayment for prescriptions received.   If a copayment is charged, it must not exceed the sliding fee structure specified in Title II of the CARE Act (see Appendix B).

h)         The Department will make a disposition and issue a written decision on an application filed pursuant to this Section within 15 days from the date the Department receives the application.  The Department will make a disposition and issue a written decision on a renewal application filed pursuant to this Section within 15 days from the date the Department receives the application. An individual may appeal the Department's denial of his/her application.  Such appeal shall be in accordance with the Department's Rules of Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100).

(Source:  Amended at 24 Ill. Reg. 11876, effective August 1, 2000)