HomeMy WebLinkAboutMINUTES - 05241994 - 1.37 To: "i . _ :'BOARD OF SUPERVISORS
FROM: Mark Finucane, Health Services Director Contra
By: Elizabeth A. Spooner, Contracts Administrator Costa
DATE: May 12, 1994
County
SUBJECT: Approve Amendment Agreement #29-395-11 with the State Department of Health
Services for County's AIDS Drug Program
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
I. RECOMMENDED ACTION:
Approve and authorize the Health Services Director, or his designee (William
Walker, M.D. ) , to execute on behalf of the County, Amendment Agreement #29-395-11,
effective October 1, 1992, to amend Standard Agreement #29-395-8, (as amended by
Amendment Agreements #29-395-9 and #29-395-10) , with the State Department of
Health Services, Office -of AIDS, to allocate additional funds for the County's
AIDS Drug Program and to extend the term of the agreement through September 30,
1994.
II. FINANCIAL IMPACT:
Approval of this amendment will result in an additional allocation of $98,862 from
the State for County's AIDS Drug Program, from $236,715, to a new total allocation
of $335,577, for the period from October 1, 1992 through September 30, 1994.
The allocation will be used to cover the cost of certain drugs for eligible low
income persons with AIDS and/or AIDS related complexes, and may not be used to
cover administrative costs as'sociated with this program or for patient monitoring,
laboratory testing, or other medical services for persons receiving any of the
drugs. The County may make provisions for co-payment by patients, commensurate
with the patient's ability to pay.
III. REASONS FOR RECOMMENDATIONS/BACKGROUND:
On March 16, 1993, the Board approved Standard Agreement #29-395-8, (as amended
by Amendment Agreements #29-395-9 and #29-395-10) with the State Office of AIDS,
for the period from October 1, 1992 through October 31, 1993, to provide funding
to cover the cost of certain drugs which have been included in the AIDS Drug
Program by the State and determined by the U.S. Food and Drug Administration to
prolong the life of a person with AIDS, for eligible low income persons who are
infected with the human immunodeficiency virus (HIV) and/or persons with AIDS and
related complexes who meet certain criteria.
Approval of this amendment adds 12 new drugs to the approved AIDS drug formulary,
provides additional funding for County's AIDS Drug Program, based upon actual and
projected drug expenditures by the Department, and extends the term of the
agreement through September 30, 1994.
Four certified and sealed copies of the Board Order should be returned to the
Contracts and Grants Unit for distribution to the State Department of Health
Services.
CONTINUED ON ATTACHMENT: YES SIGNATURE'
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMM AT N OF BOARD dOMMITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER
VOTE,OF SUPERVISORS
✓//UNANIMOUS (ABSENT ) I HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
OF SUPERVISORS ON THE DATE SHOWN.
Contact: Wendel Brunner, M.D. (313-6712)
cc: Health Services (Contracts) ATTESTED 2- _
Auditor-Controller (Claims) Phil Batch r, Clerk if the Board of
State Office of AIDS SupenlWj3WdWtyAdmu►WaW
M382/7-88 BY �gi 0-0,m- DEPUTY
Lf
AMENDMENT TO STANDARD AGREEMENT FOR
THE AIDS DRUG ASSISTANCE PROGRAM
October 1, 1992 - September 30, 1994 29 - 395 - 11
Contra Costa County
The AIDS Drug Program, hereafter known as the AIDS Drug Assistance Program, Standard
Agreement is hereby amended pursuant to Article III, No. 8 and No. 11 to augment the Local
Health Jurisdiction's maximum allocation and to extend the term of this Agreement. Therefore,
Article I, No. 3 and No. 4 are amended as follows:
3. The term of this Agreement is for the period October 1, 1992 through
September 30, 1994.
4. The maximum allocation to the Local Health Jurisdiction for the term of this
agreement shall not exceed $335,577.
The following Exhibits are hereby amended:
Exhibit A-1, entitled "AIDS Drug Assistance Program Approved Drugs" is incorporated
and made a part hereof by this reference. All further references to Exhibit A, "AIDS
Drug Program Approved Drugs" in the body of the agreement or any exhibits thereto
shall be deemed to read Exhibit A-1.
Exhibit C-1, entitled "AIDS Drug Assistance Program Financial Eligibility and Co-
Payment Worksheet" is incorporated and made a part thereof by this reference. All
further references to Exhibit C, "Payment Work Sheet" in the body of this agreement or
any exhibits thereto shall be deemed to read Exhibit C-1.
Exhibit D-1, entitled "AIDS Drug Assistance Program Invoice Foran" is incorporated and
made a part hereof by this reference. All further references to Exhibit D, "AIDS Drug
Program Invoice Form" in the body of this agreement or any exhibits thereto shall be
deemed to read Exhibit D-1.
Exhibit F-1, "AIDS Drug Assistance Program Approved Payment Amounts" is
incorporated and made a part hereof by this reference. All further references to
Exhibit F in the body of this agreement or any exhibits thereto shall be deemed to read
Exhibit F-1.
Page 1 of 2
The following Exhibit is hereby added:
Exhibit G, "AIDS Drug Assistance Program Financial Appeal" is incorporated
and made a part hereof by this reference.
IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto.
State of California Local Health Jurisdiction
Signatu Signature x
Title Chief, Early Intervention Section Titlex 17�1e "
Date 9¢ Dated S�JI/fir
Page 2 of 2
Exhibit A-1
AIDS DRUG ASSISTANCE PROGRAM
APPROVED DRUGS
REV. April 1, 1994
The following 26 drugs are on the AIDS Drug Assistance Program (ADAP) formulary. They are listed by ADAP
Series #, name(s), and indication.
# DRUG FORM INDICATION
00100 CLINDAMYCIN capsule With primaquine in PCP treatment; with pyrimethamine in
Cleocin treatment and maintenance of toxoplasmosis
00200 CLOTRIMAZOLE cream; lotion; Oral and vaginal candidiasis (yeast)
Lotrimin tablet; troche
Mycelex
Gyne-Lotrimin
00300 DAPSONE tablet PCP prophylaxis; PCP treatment; toxoplasmosis prophylaxis;
Avlosulfon toxoplasmosis treatment
00400 DIDANOSINE tablet; powder Resistance to AZT; declining CD4 on AZT; in combination
ddI with AZT
Videx
00500 FLUCONAZOLE tablet Oral candidiasis, cryptococcal meningitis; candida
esophagitis;
Diflucan coccidioidomycosis
00600 GANCICLOVIR vial Cytomegalovirus (CMV) infection; herpes simplex virus
Cytovene infection; herpes zoster infection
00700 KET000NAZOLE ' tablet; cream Oral and esophageal candidiasis
Nizoral
00800 NYSTATIN pastilles; tablet; Oral and vaginal candidiasis
Mycostatin oral suspension;
powder; pastille;
ointment; cream
00900 PENTAMIDINE aerosol; vial PCP treatment and prophylaxis
Pentam
NebuPent
01000 PYRIMETHAMINE tablet Toxoplasmosis treatment and maintenance
Daraprim
01100 SULFADIAZINE tablet In combination with pyrimethamine in treatment and
Microsulfon maintenance of toxoplasmosis
1
Exhibit A-1
01200 TMP/SMX tablet PCP treatment and prophylaxis
Bactrim
Septra
01300 ZIDOVUDINE capsule CD4 <500; patient symptomatic; elevated P24 Ag;
AZT history of AIDS related infections
Retrovir
01400 ZALCITABINE tablet Alone or in combination with AZT if CD4 # is declining;
ddC intolerance to AZT•; resistance to AZT
Hivid
01500 ACYCLOVIR capsule; tablet; HSV treatment and prophylaxis; varicella zoster virus
Zovirax ointment treatment only
01600 AMPHOTERICIN B vial Treatment and maintenance of cryptococcal meningitis;
Fungizone treatment of candida infections; treatment
of deep mycosis
01700 ATOVAOUONE tablet PCP treatment in patients with mild to moderate PCP who
Mepron, 566 are allergic to TMP/SMX
01800 AZITHROMYCIN capsule Community acquired pneumonias, bacillary angiomatosis,
Zithromax toxoplasmosis with pyrimethamine, chlamydia urethritis,
cryptosporidium diarrhea
01900 CLARITHROMYCIN tablet Toxoplasmosis, MAC, bacillary angiomatosis, community
Biaxin acquired pneumonia
02100 CLOFAZIMINE capsule MAC
Lamprene
02100 ETHAMBUTOL tablet Tuberculosis, MAC
Myambutol
02200 FLUCYTOSINE capsule With amphotericin-B in treatment of cryptococcal
5-FC meningitis and candida infections
Ancobon
02300 FOSCARNET infusion bottle CMV infections non responsive or intolerant to ganciclovir
Foscavir
02400 PAROMOMYCIN capsule Treatment of cryptosporidium diarrhea
Humitin
02500 RIFABUTIN capsule MAC treatment and prophylaxis
Mycobutin
kIDATAV W MADAPIAPPAOMUST
2
AIDS Drug Assistance Program Exhibit C-1
Office of AIDS
P.O.Box 94273
Sacramento,CA 94234-7320
AIDS DRUG ASSISTANCE PROGRAM
FINANCIAL ELIGIBILITY AND CO-PAYMENT WORKSHEET
1994
Client Name/ID## Social Security Number
(1) Annual Gross Income (Monthly Gross Income X 12 = Annual Gross Income)
or
If the applicant has a Californa Resident Income Tax Return 1993 540,skip numbers (1) and (2), and
enter their taxable income {Line 19 on form 540;Line 16 on forms 540A and 540EZ) on number (3).
If the applicant has a U.S. Indivdual Income Tax Return 1993, enter adjusted gross income
{Line 31 on Form 1040,Line 16 on Form 1040A, or Line 6 on Form 1040EZ) on number (1).
(2) Standard California Deduction (Enter deduction.) (2) $
Filing Status Amount
1 Single $2,402
2 Married filing joint return $4,804
3 Married filing separate return $2,402
4 Head of household $4,804
5 Qualifuig widow(er) $4,804
(3) Taxable Income [Subtract (2) from (1).] (3) $
If the applicant's taxable income is less than $29,440 (family of one), $39,360 (family of two),
or 49,280 (family of 3), the client has no co-payment obligation. It is not necessary to complete
numbers (4) through (8).
(4) Tag Liability [Look up on tax table using number (3) amount and filing status.] (4) $-
(5)
4) $(5) Total Monthly Co-payment [#(4) divided by 6.1 (5) $-
(6)
5) $(6) Monthly Health Insurance Premium [Subtract from (5).] (6) $
('n Net Monthly Co-payment (7) $
(8) Cost of Drug (8) $
If the cost of the drug is less than number ('n, then the cost of the drug(s) will be the
monthly co-payment.
Note: Figures may change each year with poverty level and tax changes. The revised form will be effective on May 1 of each year.
NADATA\PC&W\ADAP\FNANCIAL.FLM
1903 California Tax Table -Continuea Exhibit C-1 Page 2
If Your'Taxable The Tax For It Your Taxable The Tax For if Your Taxable The Tax For
Income is . . . Filing Status Income Is Filing Status Income Is .. . Filing Status
At But Not 1 or 3 Z Or 5 4 At But Not 1 Or 3 2 Or 5 4 At But Not 1 Or 3 2 Or 5 4
Least OverI Is Is Is Least Over Is Is Is Least Over Is Is Is
19,451 19,550 553 297 297 25,451 26,550 1,019 524 52433,451 33,550 1,616 804 904
19,551 19,650 559 299 299 26,551 26,650 1.027 528 528
_13 33,551 33,650 1,625 808 910
19,651 19,750 565 301 301 26,651 26,750 1,035 532 432 33,651 33,750 1,635 312 916
19,751 19,850 571 303 203 26,751 26,850 1,043 536 036 33,751 33,850 .1,644 816 922
19,851 19,950 577 305 305 1 25,851 26,950 1,051 540 540 -33,851 33,950 1,653 820 928
19,951 20,050 583 307 307 26,951 27,050 1,059 544 544 33,951 34,050 1,662 824 934
20,051 20,150 589 309 309 27,051 27,150 1.067 548 548 34,051 34,150 1,672 828 940
20,151 20,250 595 311 311 27,151 27,250 1,075 552 552 34,151 34,250 1,681 832 946
20,251 20,350 601 313 313 27,251 27,350 1,083 556 556 34,251 34,350 1,690 836 952
20,351 20,450 607 315 315 27,351 27,450 1,091 560 580 34,351 34,450 1.700 840 958
20,451 20,550 612 317 317 27,451 27,550 1,099 564 564 34,451 34,550 1,709 844 964
20,551 20,650 619 319 319 27,551 27,650 1,107 568 568 34,551 34,650 1,718 848 970
20,651 20,750 625 321 321 27,651 27,750 1,115 572 572 34,651 34,750 1.728 852 976
20,751 20,850 631 323 323 27,751 27,850 1,123 576 576 34,751 34,850 1,737 856 982
20,851 20,950 637 325 325 27,851 27,950 1,131 580 580 34,851 34,950 1,746 860 988
20,951 21,050 643 327 327 27"'5128,050 1,Q9 584 584 34,951 35,050 1.755 866 994
21,051 21,150 649 329 329 28,051 28,150 - 1,147 588 588 35,051 35,150 1,765 872 1.000
21,151 21,250 655 331 311 22 8,250 1,155 592 592 35,151 35,250 1,774 873 1,006
21,251 21,350 601 333 333 ::251 28,350 1,163 596 596 35,251 35,350 1,783 884 1,012
21,351 21,A50 667 335 335 28,351 28,450 1,171 600- 600 35,351 35,450. 1.793 890 1,020
21,451 21,550 673 337 337 28,451 28,550 1,179 604 604 35,451 35,550 1,302 896 1.028
21,551 21,650 679 339 339 28,551 28,650 1,187 608 610 35,551 35,650 1,811 902 1,036
21,651 21,750 685 341 341 28,651 28,750 1,195 612 616 35,651 35,750 1.821 908 1,044
21,751 21,850 691 343 343 28,751 28,850 1,203 616 622 35,751 35,850 1.330 914 1,052
21,851 21,950 697 345 345 28,851 28,950 1,211 620 628 35,861 35.950 1.839 920 1,060
21,951 22,050 703 347 347 28,951 29,050 1,219 624 634 35,951 36,050 1,848 926 1,068
72,051 22,150 709 349 349 29,051 29,150 1,227 628 640 36,051 36,150 1,858 932 1,076
22,151 22,250 715 252 352 29,151 29,250 1,235 632 646 36,151 36,250 1,867 938 1,084
22,251 22.350 721 356 356 29,251 29,350 1,243 636 652 36,251 36,350 1,876 944 1,092
22,351 22,450 727 360 360 29,351 29,450 1,251 , 640 658 36,351 36,450 1,886 950 1,100
22,451 22,550 733 264 364 29,451 29,550 1,259 644 664 36,451 36,550 1,895 956 1,108
22,551 22,650 729 368 368 29,551 29,550 1,267 648 670 36,551 36,650 1,904 962 1,116
22,651 22,750 745 372 372 29,651 29,750 1,275 652 676 36,651 36,750 1,914 968 1,124
22,751 22,850 751 376 376 29,751 29,850 1,283 656 682 36,751 36,850 1,923 974 1,132
22,851 22,950 757 380 380 29,851 29,950 1,291 660 688 36,851 36,950 1,932 980 1,140
--22-,951 23,050 763 384 384 29,951 30,050 1,299 664 694 36,951 37,050 1,941 L36 1,148
23,051 23,150 769 388 388 30,051 30,150 1,307 668 700 37,051 37,150 1,951 992 1,156
23,151 23,250 775 392 392 30,151 30,250 1.315 672 706 37,151 37,250 1,960 998 1.164
23,251 23,350 781 396 396 30,251 30,350 1,323 676 712 37,251 37,350 1,969 1.004 1,172
23,351 23,450 787 400 400 30,351 30,450 1,331 680 718 37,351 37,450 1,979 1,010 1,180
23,451 23,550 793 404 404 30,451 30,550 1,329 684 724 37,451 37,550 1,988 1,016 1,188
23,551 22,650 799 408 408 30,551 30,650 1,347 688 730 37,551 37,650 1.997 1,022 1,196
23,651 23,750 805 412 412 30,651 30,750 1,358 692 736 37,651 37,750 2,007 1,028 1,204
23,751 23,850 all 416 416 30,751 30,850 1,365 696 742 37,751 37,850 2.016 1.034 1,212
23,851 23,950 317 420 420 , 30,851 30,950 1,374 700 748 37,851 37,950 2,025 1.040 1.220
23,951 24,050 823 424 424 30,951 31,050 1,383 704 754 37,951 38,050 2.034 1,046 1,228
24,051 24,150 829 423 128 31,051 31,150 1,393 708 .760 38,051 38.150 2,044 1,052 1,226
24,151 24,250 835 432 432 31,151 31,250 1,402 712 766 38,151 38,250 2,053 1,058 1,244
24,251 24,350 843 436 136 31,251 31,350 1,411 716 772 38.251 38,350 2.062 1,064 1.252
24,351 24,450 851 .1A0 a-i0 31,351 31,450 1.1121 720 7778 38,351 38,450 2.072 1.070 1,260
24,451 24,550 859 444 444 31,451 31,550 1,430 724 714 1 31:'111 31,550 2,081 1,076 1.268
24,551 24,650 867 448 448 31,551 31,650 1,439 728 790
38,551
38'550 2.090 1,082 1.276
24,651 24,750 375 452 452 31,651 31,750 1,449 732 796 . 38,651 38.750 2.100 1.088 1,294
24,751 24,850 883 456 456 31,751 31,350 1,458 726 802 38,751 38.850 zloq 1,094 1,292
24,851 24.950 891 460 4-
60 31,851 31,350 1,467 740 808 38,851 38,950 2.118 1.100 1.300
24,951 25,050 899 464 464 31,951 32-050 1,476 744 814 38,951 39,050 2.127 1,106 1,308
25,051 - 25,150 907 468 163 32,051 32,150 1,486 748 820 39,051 39,150 2.137 1,112 1.216
25,151 25.250 915 172 472 32.151 32,250 1,495 752 826 39,151 39.250 2.146 11,118 1,324
25,251 25,350 923 476 475 32.251 32-350 1,5011 756 832 39.251 39.350 2.155 1,124 1.332
25,351 25,450 931 180 180 32,351 32.450 1.514 790 838 39.351 39.'45() 2.165 1,120 1,340
25,451 25,550 939 "84 484 32,451 32,550 1,523 764 844 39,451 39,5-0 2.174 1,136 1.3118
25,551 25.650 947 488 488 32,551 32,550 1.432 788 850 39.551 39,550 2.183 1.142 1,356
25,551 25,750 91^ 192 592 2 32,551 32,750 1.542 72 856 39.551 39,750 2.1C-3 1.1A8 1.20A
25,751 25,850 963 196 596 32,751 32,350 1,551 776 862 39,751 39,350 2,202 1,1--
4 1.372
25,851 25,950 971 500 500 32.851 32,950 1-560 780 868 39,851 39,950 2.211 1,160 1.380
25,951 26,050 979 504 504 32,951 33,050 1.569 784 374 39,951 40,050 2.220 1.166 1.138
26,051 26,150 987 508 408 33,051 33,150 1,579 788 880 40.051 40,150 2.230 i,172 1,396
26,151 26,250 995 312 512 33,151 33,250 1,488 792 386 40,151 110.250 2.229 1.173 1,404
26.251 26,350 1,003 516 516 33.251 33,350 1-197 796 892 40,251 40,350 2,248 1.184 1,412
26,351 26,450 1,011 5520 420 33,351 33,450 1,507 sco 898 40.351 . 40,450 2.258. 1.190 1.420
Tice -lax table is continued on page 46.
Personal !ncl-ma Tax Booklet 1993 Page 45
1993. California Tax Table -Continued Exhibit C-1 Page 3
It Your Taxable The Tax For if Your Taxable The Tax For I If Your TaxableI ,The Tax For
Income Is . . . i Filing Status I Income Is... Filing Status Income Is . . . Filing Status
At But Not 11 Or 3 2 Or 5 4I At But Not 11 Or 3 2 Or 5 4 I At But Not 11 Or 3 2 Or 5 4
Least Over Is Is Is Least Over Is Is Is Least Over Is Is Is
40,451 40,550 2,267 1,196 1,428 43,951 44,050 2.592 1,406 1,739 47,451 47,550 2,918 1,616 2,064
40,551 40,550 2.276 1,202 1,436 44,051 44,150 2,602 1,412 1,748 47,551 47,650 2,927 1,622 2.073
40,651 40,750 2.286 1,208 1,444 44,151 44,250 2.611 1,418 1,757 47,651 47,750 2.937 1.628 2.083
40,751 40,850 2,295 1.214 1,452 44,251 44,350 2,620 1,424 1,766 47,751 47,850 2.946 1.534 2.092
40.851 40.950 2.304 1,220 1.460 44,351 44,450 2,530 1,430 1,776 47,851 47,950 2.955 1.640 2.101
40,951 41,050 2.313 1,226 1,46844,451 44,550 2,639 1,436 1,785 47,951 48,050 2,964 1,646 2.111
41,051 41,150 2,323 1,232 1,476 44,551 44,650 2,648 1,442 1,794 48,051 48,150 2,974 1,652 2.120
41,151 41,250 2,332 1,238 1,484 44,651 44,750 2,658 1,448 1,804 48,151 48,250 2,983 1,658 2.129
41,251 41,350 2,341 1.244 1,492 44,751 44,850 2,667 1,454 1,813 48,251 48,350 2,992 1,664 2,138
41,351 41,450 2,351 1.250 1,500 44,851 44,950 2,676 1,460 1.822 48,351 48,450 3,002 1,670 2,148
41,451 41,550 2,360 1,256 1,508 44,951 45,050 2,685 1,466 1,832 48,451 48,550 3,011 1,677 2,157
41,551 41,650 2.369 1,262 1,516 45,051 45,150 2,695 1,472 1,841 48,551 48,650 3,020 1,685 2.166
41,651 41,750 2.379 1,268 1,525 45,151 45,250 2,704 1,478 1,850 48,651 48,750 3.030 1,593 2.176
41,751 41,850 2.388 1.274 1,534 45,251 45,350 2,713 1,484 1,859 48,751 48,850 3,039 1,701 2.185
41,851 41,950 2.397 1,280 1,543 45,351 45,450 2.723 1,490 1,869 48,851 48,950 3,048 1,709 2.194
41,951 42,050 2,406 1,286 1,553 45,451 45,550 2,732 1,496 1,876 48,951 49,050 3.057 1,717 2.204
42,051 42,150 2.416 1,292 1.562 45,551 45,650 2,741 1,502 1,887 49,051 49,150 3.067 1,725 2.213
42,151 42,250 2.425 1,298 1.571 45,651 45,750 2.751 1,508 1.897 49,151 49,250 3.076 1,733 2.222
42,251 42,350 2.434 1,304 1,580 45,751 45,850 2,760 1,514 1,906 49,251 49,350 3,085 1,741 2.231
42,351 42.450 2.444 1.310 1,590 45,851 45,950 2.769 1,520 1,915 49,351 49,450 3.095 1,749 2.241
42,451 42,550 2.453 1,316 1,599 45,951 46,050 .2,778 1,526 1,925 49,451 49,550 3,104 1,757 2,250
42,551 42.650 2.462 1,322 1,608 46,051 46,150 2,788 1,532 1,934. 49,551 49,650 - 3,113 1,765 2.259
42,651 42,750 2,472 1,328 1,618 46,151 46,250 2,797 1.538 1,943 49,651 49,750 3,123 1,773 2.269
42,751 42,850 2,481 1,334 1,627 46,251 46,350 2,806 1,54.4 1,952 49,751 49,850 3,132 1,781 2,278
42,851 42.950 2,490 1,340 1,636 46,351 46,450 2,816 1,550 1,962 49;851 49,950 3,141 1,789 2.297
42,951 43,050 2.499 1,346 1,646 1 46,451 46,550 2,825 1,556 1,971 49,951 50,000 3,148 1,795 2,294
43,051 43,150 2,509 1,352 1,655 46,551 46,650 2.834 1,562 1,980 OVER S50,000 YOU MUST COMPUTE
43,151 43,250 2,518 1,358 1,664 46,651 46,750 2,844 1,56a 1,990 YOUR TAX USING THE TAX RATE
43,251 43,350 2,527 1,364 1,673 46,751 46,850 . 2,853 1,574 1,999
43.351 43,450 2,537 1,370 1,683 46,851 46,950 2,862 1,580 2,008 SCHEDULES BELOW.
43,451 43,550 2,546 1,376 1,692 46,951 47,050 2,871 1,586 2,018
43,551 43,650 2.555 1,382 1,701 47,051 47,150 2,881 1,592 2.027
43,651 43,750 2,565 1,388 1,711 47,151 47,250 2,890 1,598 2,036
43,751 43,850 2.574 1,394 1,720 47,251 47,350 2.899 1,604 2,045
431,851 43,950 2,583 1.400 1,729 47,351 47,450 2,909 1,610 2,055
Exhibit D-1
State.of California Authorizedwithouta supporting
Department of Health Services Contract per HSC Sec. 188.1(b),
Office of AIDS AB 2251,Chapter 1246,Stat of 1989
P. O. Box 942732
Sacramento,CA 94234-7320
AIDS DRUGS ASSISTANCE PROGRAM INVOICE FORM
This form must be submitted with original signatures. Copies should be retained for the local
health jurisdiction's records.
1. Name of Local Health Jurisdiction:
2. Address:
3. Invoice for the month of , 19
4. Total number of prescriptions provided for month invoiced (excluding nebulizers and
other equipment used in administering drugs):
5. Total cost of drugs, excluding dispensing fee: $
6. Total cost of dispensing fees: $
7. Total cost of drugs and dispensing fees: $
(5 + 6)
8. Amount reimbursed by insurance: $
9. Total amount of copayment: $
10. Net amount to be reimbursed by State $
ADAP [7 - (8 + 9)]:
Report prepared by:
(Telephone)
I hereby certify, under penalty of perjury, that the above services have been provided in accordance with the policies,
guidelines and standards of the State Department of Health Services and that the fees do not exceed those authorized for
this program.
Signature of a Duly Authorized Health Jurisdiction Official Date
-STATE OFFICE OF AIDS USE ONLY-
YW MR Cc&
�L I . �U I I I I -L Li
AIDE D4UGAS6ISTANCE PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS Exhibit F-1
CODE GENERIC NAME TRADE NAME FORM STRENGTH MAXIMUM AMT.
REIMBURSED
00100 1 CLINDAMYCIN HCL Cleocin
00101 Cleocin capsule 75mg 0.4493
00102 Cleocin capsule 150mg 0.8325
00103 Cleocin capsule 300mg 1.7701
00200 CLOTRIMAZOLE . Lotrimin, Mycelex
00201 Lotrimin, Mycelex tube,cream 1% 15mg 9.3855
00202 Lotrimin, Mycelex tube,cream 1% - 30mg 15.9120
00203 Lotrimin, Mycelex tube,cream 1% 45mg 19.3140
00204 Lotrimin, Mycelex tube,cream 1% 90mq 26.4510
00205 G ne-Lotrimin, Mycelex-G vaginal tablet 100mg 1.6286
00206 Gyne-Lotrimin, Mycelex-G vaginal tablet 500mg 10.4310
00207 Lotrimin, Mycelex bottle, solution 1% 10cc 8.2560
00208 Lotrimin, Mycelex bottle, solution 1% 30cc 17.1750
00209 M celex troche,70/bottle 10mg 45.3740
00210 Lotrimin, Mycelex troche, 140/bottle 10mg 86.8395
00211 Gyne-Lotrimin, Mycelex-G lotion 1%,bottle 30mg 17.9730
00212 G ne-Lotrimin, Mycelex-G tubes,vaginal 1%cream 45mg 12.7485
00213 Lotrimin, Mycelex tubes,va inal 1%cream 90mg 23.2200
00300 DAPSONE Avlosulfon
00301 Avlosulfon tablet 25mg 0.1634
00302 Avlosulfon tablet 100mg 0.1710
00400 DIDANOSINE ddl, Videx
00401 ddl,Videx tablet 25mg 0.3421
00402 ddl,Videx tablet 50mg 0.6841
00403 ddl,Videx tablet 100mg 1.3682
00404 ddl,Videx tablet 150mg 2.0240
00405 ddl,Videx pckt of 30,powdr for sol. 100mg 41.0495
00406 ddl,Videx pckt of 30,powdr for sol. 167m 68.5520
00407 ddl,Videx ckt of 30, owdr for sol. 250mg 102.6190
00408 ddl,Videx pckt of 30, powdr for sol. 375m - 153.9285
00500 FLUCONAZOLE Diflucan
00501 Diflucan tablet 50mg 3.6843
00502 Diflucan tablet 100mg 5.7893
00503 Diflucan tablet 200mg 9.4737
00600 GANCICLOVIR Cytovene
00601 Cvtovene vial 500mg 33.0600
00700 KETOCONAZOLE Nizoral
00701 Nizoral tube,2%cream 15gm 11.6730
00702 Nizoral tube,2%cream 30gm 19.6200
00703 Nizoral tube, 2%cream 60gm 29.8080
00704 Nizoral tablet 200mg 2.3389
00800 NYSTATIN I Mycostatin
00801 Mycostatin tablet,vaginal 10oKu 1.0719
00802 Mycostatin bottle,oral suspension T60cc 3.2880
00803 Mycostatin tablet,oral 500Ku 0.5254
00804 Mycostatin astille/lozn a 200Ku 0.8838
00805 I I Mycostatin tube,ointment 100Ku/ m 15gm 1.4550
00806 Mycostatin tube,ointment 100Ku/gm 30gm 3.1350
00807 I Mycostatin tube,cream 100Ku/ m 15gm 1.4550
00808 Mycostatin tube,cream 100Ku/ m 130gm 2.4000
H:\USERS\BHARTZ\123\MAXPRICE.WK1 1 Effective April 1, 1994
AIDS DIRUGASSISTANCEPROGRAM MAXIMUM REIMBURSEMENT AMOUNTS Exhibit F-1
CODE GENERIC NAME TRADE NAME FORM STRENGTH MAXIMUM AMT.
REIMBURSED
0900 PENTAMIDINE NebuPent, Pentam
00901 NebuPent aerosol 300mg 93.8125
00902 Nebulizer nebulizer for NebuPent 15.0000
00903 Pentam vial 300mg 95.0000
01000 PYRIMETHAMINE Daraprim
01001 Dara rim tablet - 25mg 0.3301
01100 SULFADIAZINE Microsulfon
01101 Microsulfon tablet 500mg 0.4774
01200 TMP/SMX Bactrim, Septra
01201 Bactrim, Septra 1 tablet 80/400 regular 0.0743
01202 Bactrim,Septra tablet 160/800 double 0.0863
01300 ZIDOVUDINE AZT, Retrovir
01301 AZT, Retrovir capsule 100mg 1.3702
01400 ZALCITABINE ddC, HIVID
01401 ddC, HIVID tablet 0.375mg 1.6188
01402 ddC, HIVID tablet 0.750mg 2.0292
01500 ACYCLOVIR Zovirax
01501 Zovirax capsule 200mg 0.8918
01502 Zovirax tablet 400mg 1.7307
01503 Zovirax tablet 800mg 3.3655
01504 Zovirax ointment%5 - 3gm 13.5470
01505 Zovirax ointment%5 15gm 1 31.3310
01600 AMPHOTERICIN B Fungizone
01601' Fun izone vial 150mg 14.2500
01602 Fun izone vial 100m 16.6250
01700 ATOVAQUONE Mepron, 566
01701 Mepron,566 tablet 250mg 2.4282
01800 AZITHROMYCIN Zithromax
01801 Zithromax capsule 250mg 7.71881
01900 CLARITHROMYCIN Biaxin
01901 Biaxin tablet 250m 2.3182
01902 Biaxin tablet 500mg 2.3182
i
02000 CLOFAZIMINE Lamprene,
02001 1 Larnlorene capsule 50mg 0.1189
02002 Lam rene capsule 100mg 0.2203
02100 'ETHAMBUTOL M ambotol
02101 1 Myambutol tablet 100m I 0.3350
02102 Myambutol tablet 1400mg 1 1.1209
I I �
02200 1 FLUCYTOSINE 5-FC, Ancobon
02201 5-FC,Ancobon capsule 1250mg 0.9529
02202 5-FC,Ancobon capsule 500mg 1.83431
1
02300 FOSCARNET Foscavir
02301 I 1 Foscavir infus bottle 24mg/cc 250cc I 49.6250
02302 Foscavir infus bottle 24mg/cc 1500cc I 138.65001
H:\USERS\BHARTZ\123\MAXPRICE.WK1 2 Effective April 1, 1994
AIDS DRUG.ASSISTANCE-PROGRAM MAXIMUM REIMBURSEMENT AMOUNTS Exhibit F-1
CODE GENERIC NAME TRADE NAME FORM STRENGTH MAXIMUM AMT.
REIMBURSED
02400 PAROMOMYCIN Humitin
02401 Humitin capsule 250mg 1.7132
02500 RIFABUTIN Mycobutin
02501 Mycobutin capsule 1 50mg 3.2419
H:\USERS\BHARTZ\123\MAXPRICE.WK1 3 Effective April 1, 1994
'Stateof California Healtlrand Welfa4e Agency Exhibit G
Office of AIDS
AIDS Drug Assistance Program
Financial Appeals
County
Please discuss any questions about the AIDS Drug Assistance Program with a program representative. Financial
eligibility,and the requirement for enrollees to share in the cost of drugs are set by State law. You have the right
to appeal decisions about your financial eligibility or the amount of your payment obligation. Attach any additional
information to this form or write additional information on the back of this form. All appeals must be in writing.
Send your appeal to:
The State Office of AIDS
Department of Health Services
AIDS Drug Assistance Program
P. O. Box 942732
Sacramento, CA 94234-7320
1. Client Name/ID#: Birthdate:
Social Security Number:
Address:
2. Appeal Made By:Name:
Relation To Client: Telephone:
TO BE FUJM OUT BY CLffiVT
3. This appeal concerns:0 Financial eligibility 0 Payment obligation
4. Is it based on: 0 A substantial change in income
S. My payment obligation for the period through
was set at$ I believe this should be changed because:
Signature Date
6. Decision by Office of AIDS
Signature Date
Title
The information on this form is required by the Office of AIDS,Department of Health Services in order to determine your eligibility for services.
The information is maintained pursuant to Section 188.2 of the California Health and Safety Code. If you do not provide this information,
eligibility for services may be denied. If you have any questions regarding your appeal,please contact the AIDS Drug Assistance Program,
Office of AIDS,P. O. Box 942732,Sacramento,CA 94234-7320 or phone(916)327-6784.
N:\DATA\PC&W\ADAP\FINANCIA.APP