Form B - ADR Grantee Report

OMB No.: 0915-0345

Expiration Date: XX/XX/20XX

AIDS Drug Assistance Program

ADR Grantee Report

Revised Grantee-Level Variables

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915–0345. Public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, MD 20857.

COVER PAGE (All Values Autopopulated)

Grantee Contact Information

1. Grantee name:______________________________________________________________________________

2. Grant number:

3. D-U-N-S number:

–

-

4. Grantee address:

1. Street:

2. City: State:

3. ZIP Code: __ __ __ __ __ - __ __ __ __

5. Contact information of person completing the Grantee Report:

1. Name:

2. Title:

3. Phone #: (__ __ __) __ __ __ - __ __ __ __

4. Fax #: (__ __ __) __ __ __ - __ __ __ __

5. E-mail:

Section 1: Programmatic Summary Submission

All items in the Grantee Report should be reported for the most recent grant year. Please review the Instructions for Completing the ADAP Grantee Report to ensure that you respond to each item appropriately.

A. PROGRAM ADMINISTRATION

1. Please indicate which of the following limits applied to your ADAP during the reporting period. For each item that applied, complete the blank with the information requested on that limit. (Check all that apply)

• Waiting list anytime during the reporting period

• Enrollment cap                                     Max number of enrollees __________

• Capped expenditure                             Monetary cap    $______per client

• Drug-specific enrollment caps for ARVs or Hepatitis C medications - Please specify below for each medication that has an enrollment cap:

Medication _____________________

• None of these limits were applied to the ADAP during the reporting period

2. Please indicate the maximum ADAP eligibility requirements as a percentage of Federal Poverty Level (FPL):

________________ %

3. Please indicate the clinical eligibility criteria required to enroll in the ADAP in your State/Territory: (Check all that apply)

• CD4 (please specify the CD4 count requirement ____________________)

• Viral load (please specify the VL count requirement _____________________________)

• Other (please specify: _____________________________)

• No clinical eligibility criteria required to enroll in the ADAP

b. PURCHASING MECHANISMS

4. Please check all that apply to your Drug Pricing Program: (Check all that apply)

• 340B (please specify below)

• Rebate

• Hybrid

• Direct purchase

• Prime vendor

• Alternative Method Demonstration Project

• Department of Defense

• None of these apply to our Drug Pricing Program

C. FUNDING

5. Please enter the funding received during this reporting period from each of the following sources (if no funding was received enter “0"):

	Funding Source	Amount Received (to nearest dollar)
a.	Total contributions from Part A EMA(s)/TGAs	$
b.	Total contributions from Part B Base Funding	$
c.	Total contributions from Part B Supplemental Funding	$
d.	Total contributions from ADAP Emergency Relief Funding	$
e.	Total contribution from Part C/D grantees	$
f.	State contributions for ADAP (other than Ryan White)	$
g.	Carry-over of Ryan White funds from previous year	$
h.	Manufacturer Rebates	$
j.	All Insurance Reimbursements, excluding Medicaid	$
k.	Medicaid Reimbursements	$
	Resources received this reporting period (Total of a through k)	$

D. EXPENDITURES

6. For each of the following categories, please enter total expenditures for this reporting period:

	Expenditure Category	Total Cost
a.	Pharmaceuticals	$
b.	Dispensing costs	$
c.	Other administrative costs	$
d.	Insurance coverage (including co-pays, deductibles, and premiums)	$
	Total ADAP expenditures this reporting period	$

E. ADAP MEDICATION FORMULARY

7. Please provide information on Antiretroviral (ARV), hepatitis B, hepatitis C and ‘A1’-OI medications currently on your ADAP formulary. If you added an ARV medication to your ADAP formulary during this reporting period, please note that and provide the date that it was added.

1. Grantee-level Formulary Information – Antiretroviral Medications

Included In Formulary	GENERIC NAME	BRAND NAME	Drug Identification Number	Added to Formulary this Reporting Period
				Med Added?	Date Added
	abacavir	Ziagen	d04376		MM/DD/YYYY
	abacavir/lamivudine/zidovudine	Trizivir	d04727		MM/DD/YYYY
	abacavir/lamivudine	Epzicom	d05354		MM/DD/YYYY
	atazanavir	Reyataz	d04882		MM/DD/YYYY
	darunavir	Prezista	d05825		MM/DD/YYYY
	delavirdine	Rescriptor	d04119		MM/DD/YYYY
	didanosine	Videx/Videx EC	d00078		MM/DD/YYYY
	dolutegravir	Tivicay	d08117		MM/DD/YYYY
	efavirenz	Sustiva	d04355		MM/DD/YYYY
	Efavirenz/emtricitabine/tenofovir	Atripla	d05847		MM/DD/YYYY
	Elvitegravir/cobicistat/tenofovir/ emtricitabine	Stribild	d07899		MM/DD/YYYY
	emtricitabine	Emtriva	d04884		MM/DD/YYYY
	Emtricitabine/rilpivirine/tenofovir	Complera	d07796		MM/DD/YYYY
	Emtricitabine/tenofovir	Truvada	d05352		MM/DD/YYYY
	Enfuvirtide	Fuzeon	d04853		MM/DD/YYYY
	Etravirine	Intelence	d07076		MM/DD/YYYY
	Fosamprenavir	Lexiva	d04901		MM/DD/YYYY
	Indinavir	Crixivan	d03985		MM/DD/YYYY
	lamivudine	Epivir	d03858		MM/DD/YYYY
	Lamivudine/zidovudine	Combivir	d04219		MM/DD/YYYY
	Lopinavir/ritonavir	Kaletra	d04717		MM/DD/YYYY
	maraviroc	Selzentry	d06852		MM/DD/YYYY
	nelfinavir	Viracept	d04118		MM/DD/YYYY
	nevirapine	Viramune/ Viramune XR	d04029		MM/DD/YYYY
	Raltegravir	Isentress	d07048		MM/DD/YYYY
	rilpivirine	endurant	d07776		MM/DD/YYYY
	ritonavir	Norvir	d03984		MM/DD/YYYY
	Saquinavir	Fortovase/ invirase	d03860		MM/DD/YYYY
	stavudine	Zerit	d03773		MM/DD/YYYY
	tenofovir	Viread	d04774		MM/DD/YYYY
	Tipranavir	aptivus	d05538		MM/DD/YYYY
	zidovudine	Retrovir	d00034		MM/DD/YYYY

2. Grantee-level Formulary Information – A1-OI Medications

Included In Formulary	GENERIC NAME	BRAND NAME	Drug Identification Number
	acyclovir	Zovirax	d00001
	amphotericin B deoxycholate	Fungizone	d00077
	amphotericin B(liposomal)	Ambisome	d04238
	amphotericin B lipid complex	Abelcet/Amphotec/Ampholip	d03870
	azithromycin	Zithromax	d00091
	cidofovir	Vistide	d04028
	clarithromycin	Biaxin	d00097
	clindamycin	Cleocin	d00043
	Ethambutol	Myambutol	d00068
	famciclovir	Famvir	d03775
	fluconazole	Diflucan	d00071
	flucytosine	Ancobon	d00038
	foscarnet	Foscavir	d00065
	ganciclovir	Cytovene	d00066
	Isoniazid (INH)	Lanizid, Nydrazid	d00101
	itraconazole	Sporonox	d00102
	leucovorin calcium	Wellcovorin	d00275
	Norfloxacin	Noroxin/Chibroxin	d00113
	pentamidine	Nebupent	d00030
	posaconazole	Noxafil	d05853
	prednisone	Deltasone, Liquid Pred, Metocorten, Orasone, Panasol, Prednicen-M, Sterapred	d00350
	Primaquine	Primaquine	d00351
	Probenecid	Benemid	d00031
	pyrazinamide (PZA)	Rifater	d00117
	pyrimethamine	Daraprim	d00364
	rifabutin	Mycobutin	d01097
	rifampin (RIF)	Rifadin, Rimactane	d00047
	sulfadiazine (oral generic)	Microsulfon	d00118
	trimethoprim-sulfamethoxazole (TMP/SMX)	Bactrim, Septra	d00124
	valacyclovir	Valtrex	d03838
	valganciclovir	Valcyte	d04755

3. Grantee-level Formulary Information – Hepatitis B and C Medications

Included In Formulary	GENERIC NAME	BRAND NAME	Drug Identification Number
	adefovir	Hepsera	d04814
	boceprevir	victrelis	d07774
	entecavir	Baraclude	d05525
	interferon alfa-2a	Roferon-A	d01368
	interferon alfa-2b	Intron A	d01369
	interferon alfa-2b/ ribavirin	Rebetron	d04321
	lamivudine	Epivir HBV	d03858
	peginterferon alfa-2a	Pegasys/Pegasys Proclick Autoinjector	d04821
	peginterferon alfa-2b	Pegasys/Pegintron Redipen/Sylatron	d04746
	Ribavirin	Copegus/RIbapik/Virazole/Ribatab/ Rebetol	d00085
	Simeprevir	Olysio	d08182
	Sofosbuvir	Sovaldi	d08184
	Telaprevir	Incivek	d07777
	telbivudine	Tyzeka	d05912
	Interferon alfacon-1	infergen	d04224

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6/28/2017