1. What are the eligibility requirements for the DC Health Pharmacy Benefits Program (PBP), AIDS Drug Assistance Program (ADAP)?

• Proof of HIV Diagnosis: Individuals must have a positive HIV diagnosis. See elligibility requirements.
• Residency Within Washington DC: Applicants for DC Health PBP must be residents of Washington DC. U.S. citizenship is not required. Non-U.S. citizens and undocumented individuals may apply to the DC Health PBP for eligibility determination.
• Financial Eligibility: Income eligibility is based on the Federal Poverty Level (FPL), which varies based on household size and household income. The maximum FPL to be eligible for DC Health PBP is 500% of the FPL. The FPL chart can be found .

2. What documentation is required for DC Health PBP enrollment?

There are several forms and documents that are required to be submitted for enrollment into DC Health PBP. View the full list of acceptable documents.

3. Where should clients submit their documentation and how should applications be submitted to DC Health PBP office?
Completed applications must be sent to DC Health PBP via the on-line portal, mail, in-person drop-off, and
fax.

• Electronic Submission through the on-line portal.
• Mailing Address:
  DC Health – Government of the District of Columbia
  Confidential Area/3rd Fl
  2201 Shannon Place SE
  Washington, DC 20020
• In-Person Drop-Off: Please call the PBP hotline before coming to the office to ensure a staff member will be available to see you.
  • PBP Hotline: (202) 671-4815
  • Pharmacy Benefits Program address 
    2201 Shannon Place SE, Washington, DC 20020
  • Metro access: Anacostia Metro Station
• Fax Number: (202) 673-4365. Electronic submission via the online portal is preferred.

4. What are the services that DC Health PBP offers?

• Full Coverage: This benefit is for clients who do not have any insurance coverage for their medications. PBP will pay for the cost of these client’s medications. Clients with the DC Alliance may be eligible for this benefit.
• Copayment Assistance: This benefit is for clients who have health insurance but need assistance with the copayment.
• Premium Assistance: This benefit is for clients who request assistance with their monthly health insurance premium.

5. What medications are covered by the DC Health PBP?
All approved medications can be viewed on the PBP Formulary.

6. Can a DC Health PBP client go to any pharmacy to fill their medication(s)?
No, a DC Health PBP client must use a pharmacy within the DC Health PBP pharmacy network. 

7. How often do I need to recertify?
Clients are required to recertify before their eligibility expires.

• Full Coverage Clients: these clients must recertify their eligibility annually.
• Copayment and Premium Assistance: these clients must recertify their eligibility every 6 months. This includes clients who receive only medication copayment assistance or both premium and medication copayment assistance. Throughout the year, if there are any changes in your eligibility (i.e. change in income, change of home address, or change in insurance) you must update DC Health PBP with those changes.

8. What is the earliest and latest time to submit your recertification for DC Health PBP?
You can submit your recertification 30 days before your DC Health PBP eligibility expires. If your eligibility is expired for more than 1 month, then you will need to submit a full annual application to renew your DC Health PBP eligibility.

9. Can someone apply for DC Health PBP while waiting for the results of their Medicaid application?
No, clients who are eligible for Medicaid are ineligible for DC Health PBP services. While waiting for Medicaid approval or denial, clients can access medication coverage through the Emergency Financial Assistance Medication services through Housing Counseling Services. Phone number: (202) 667-2681.

10. How long does it take to process DC Health PBP applications?
Once a completed application (including all required documentation) is submitted, it may take up to two weeks for processing.

11. Can a client switch their DC Health PBP benefit type to a different benefit type before their eligibility expires?
Yes, clients may change the benefit they receive from DC Health PBP. For example, a Full Coverage client that gains insurance during their eligibility period can change the benefit they receive, to get medication copayment and/or premium assistance. Notify DC Health PBP immediately if there are any changes.

12. What are some other key details regarding DC Health PBP Health Insurance Premium and Copay Assistance?

• First Premium Invoice: The beginning of an insurance policy must be 30 days after the client enrolls to allow PBP the opportunity to make payment on the first invoice and prevent a lapse in coverage. 
• Types of Health Insurance: PBP can offer premium or copay assistance for health insurance plans that cover HIV medications. This includes health insurance plans through DC Health Links, through a client’s employer, COBRA, and through Medicare Part D.
• Premium Subsidy: For any client who has a health insurance plan through DC Health Link, they MUST also apply for the premium tax credit. Clients are required to apply for the tax credit in coordination with their insurance application. This subsidy helps lower the cost of the health insurance premium. 
• Other Family Members: DC Health PBP cannot pay for the family members of a client who are also not enrolled into PBP.
• How Are Payments Made: Payments are made directly to the health insurance company or employer, not to the client.
• Employer Insurance: Payment made to an employer-based plan is made directly to the employer (as part of a group plan) and it covers only the employee’s portion of the premium. The employer must agree to the PBP making payments on behalf of the client. 

13. Will DC Health PBP cover medications, premiums, or co-payments? 
The PBP is the payer of last resort for medications, which means PBP funds may not be used for any service, if it can reasonably be expected to be made under any state compensation program, an insurance policy, or under any federal or State health benefits program. 

14. Are there any other resources available for people living with HIV/AIDS in DC?
Additional information for assistance on cost services related to medical care, food, housing, and more in the DC Metropolitan Area can be found at LinkU.