NOTICE OF AVAILABILITY OF FUNDS AND APPLICATION INSTRUCTIONS

NOTICE OF AVAILABILITY OF FUNDS AND APPLICATION INSTRUCTIONS PRESCRIPTION DRUG ASSISTANCE PROGRAM SUPPORT FOR PRIMARY CARE CLINICS JUNE 14, 2005

TABLE OF CONTENTS I. Purpose of the Medication Assistance Program... 3 II. Funding Strategy for the Program... 4 III. Eligibility... 4 IV. Funding Guidelines... 5 V. Instructions for Submission of Proposal... 6 Definitions and Descriptions... 6 Budget Instructions... 6 Personnel Allocation by Program... 8 Budget Narrative... 8 Program Narrative... 8 Written Agreements, Letters and Supporting Documents... 9 VI. Reporting Requirements... 10 VII. Contact Information... 11 APPENDIX FORMS AND INSTRUCTIONS: FACE PAGE: APPLICATION FOR GRANT NOTICE OF INTENT TO APPLY BUDGET FORM PERSONNEL ALLOCATION BY PROGRAM KDHE Page 2 of 12 June 15, 2005

MEDICAL ASSISTANCE PROGRAM: PRESCRIPTION DRUG ASSISTANCE PROGRAM SUPPORT FOR PRIMARY CARE CLINICS I. Purpose of the Medication Assistance Program (MAP) The 2005 Kansas Legislature added $750,000.00 to the State Fiscal Year 2006 budget of the Kansas Department of Health and Environment (KDHE) and established an account for prescription support for community based primary care clinics. The purpose of these funds is to improve access to prescription drugs for Kansans served by certain federally qualified health centers 1 (FQHCs) and community-based public or not-for-profit primary care clinics. The funding was originally proposed in Senate Bill 84 which provided for three forms of financial assistance to community-based primary care clinics. The first category of support was for purchase of drug inventory under section 340B. Section 340B limits the cost of drugs to federal purchasers and to certain grantees of federal agencies including the FQHCs (also known as Community Health Centers CHC) and FQHC Look-Alikes established by the Health Resources and Services Administration, Bureau of Primary Health Care. The 340B Drug Pricing Program is authorized through Public Law 102-585, the Veterans Health Care Act of 1992, which is codified as Section 340B of the Public Health Service Act. The second method of support is to provide a subsidy for each prescription to a qualifying individual. The legislation authorizes a subsidy for a portion of the cost of prescription drugs purchased through the 340B program for patients on a sliding fee scale. The estimated average subsidy is $4.00 per prescription. The cost of these two methods of support was calculated to be approximately $424,000. The third category of support is to cover operating costs of Medication Assistance Programs (MAP), also known as manufacturers indigent drug or Prescription Medication Assistance (PMA) programs. Funds could be used for the operational costs of hiring persons to administer the various pharmaceutical industry assistance programs. Staff would coordinate the application procedures and eligibility requirements for physicians and patients in order to obtain supplies of free, or low-cost pharmaceuticals through manufacturers indigent drug programs. In these programs, filled prescriptions are mailed directly to the 1 http://bphc.hrsa.gov/programs/chcprograminfo.asp KDHE Page 3 of 12 June 15, 2005

physician and under physician supervision certain licensed personnel may disburse the medication to patients of the clinic. II. Funding Strategy: Funds authorized for SFY 2006 are intended to support start-up expenses and some operating costs for expanding access to prescription drugs. These funds will be made available to qualified applicants submitting project proposals meeting one or more of the following objectives: 1. Implement federal discount drug pricing program 2 (Section 340B pharmaceutical discount purchasing program), eligibility restricted to qualifying Community Health Centers, also referred to as Federally Qualified Health Centers (FQHC) and FQHC Look-Alikes. inventory acquisition or formulary expansion, and/or prescription subsidy for sliding fee discounts to qualified clients 2. Employ professional staff. CHCs participating in the 340B program are eligible, for example, to hire qualified health care providers to disburse drugs. 3. Hire dedicated staff to manage medication resources acquired through participation in pharmaceutical manufacturers prescription drug assistance programs, also known as indigent drug programs or patient assistance programs. Non-FQHC facilities could employ staff to coordinate and conduct MAP activities. III. Eligibility Eligibility is limited to not-for-profit or publicly-funded primary care clinics, including federally qualified community health centers and federally qualified community health center look-alikes as defined by 42 U.S.C. 330. Clinics must provide comprehensive primary health care services, offer sliding fee discounts based upon household income and serve any person regardless of ability to pay. Policies determining individual patient/client eligibility due to income or insurance status may be determined by each community but must be clearly documented and posted. 2 Federal Office of Pharmacy Affairs website: http://bphc.hrsa.gov/opa/howto.htm The 340B Drug Pricing Program resulted from enactment of Public Law 102-585, the Veterans Health Care Act of 1992, which is codified as Section 340B of the Public Health Service Act. Section 340B limits the cost of drugs to federal purchasers and to certain grantees of federal agencies. Significant savings on pharmaceuticals may be seen by those entities that participate in this program.

IV. Funding Guidelines Requests are expected to range between $25,000 and $75,000 based upon project objectives. Applicants with small, start-up projects are encouraged to apply. Requests exceeding $100,000 will be considered, based on demonstrated need and the availability of funding. Application Process and Term Of Grants Funding is available for the state fiscal year beginning July 1, 2005 and ending June 30, 2006. Applications will be accepted for one of two funding periods. Applications for the 12-month funding period July 1, 2005 through June 30, 2006 will be due on June 30, 2005. If this deadline cannot be met, applications for a 10-month funding period September 1, 2005 through June 30, 2006 must be submitted by August 15, 2005. For the later deadline, a Notice of Intent to apply for funding must be submitted by June 30, 2005 (see Appendix for Notice of Intent Form). Factors to Consider in Funding Requests - Applicants with proposals to support staff salaries and benefits are required to provide local support which meets the local match requirement of one dollar for each one dollar of funding awarded through this program. Funding for continuation requires Legislative authorization and funding beyond this year is not assured. Fiscal control and fund accounting procedures must exist to assure the proper disbursement and accounting of grant funds. A separate bookkeeping account should be established and maintained for grant-supported activities reflecting all receipts, obligations, and revenue, including non-cash contributions and disbursement of grant and local funds. The applicant will be fully responsible for providing workers compensation, unemployment insurance and social security coverage. The local health agency is also responsible for income tax deductions, and for providing any benefits required by law for those employees who are employed on behalf of the grant program. Factors Considered In Funding Decisions The key criteria for funding consideration will be Medication Assistant Project proposals that focus on new service to vulnerable populations, strengthen an organization s capacity to fulfill its mission and/ or enhance its ability to operate efficiently and effectively. KDHE Page 5 of 12 June 15, 2005

KDHE will notify all applicant organizations in writing of the decision to deny a funding request. V. Instructions for Submission of Proposal The completed materials must be assembled in the following order: a. Face Page: APPLICATION FOR GRANT (see Appendix page 13) b. Budget Form (see Appendix page 17-18) c. Personnel Allocation by Program (see Appendix page 19) d. Budget Narrative e. Project Narrative f. Written Agreements (if a pharmacy or other partner is included in the proposal) g. Letters of Support (not required) h. Copy of most recent audit (if not already on file with KDHE) DEFINITIONS / DESCRIPTIONS OF SPECIFIC PROGRAM INFORMATION a. Face Page: Specify all clinical location(s) of your organization if it is different from the applicant address. The form must be signed by the president or chairperson of the board of directors. b. Expenditure Budget: The budget is the financial plan required to achieve the overall management of the medication assistance project. c. Non-cash contributions such as personnel time, space, commodities, or services, must be given a fair market value and documented in the local organization accounting records. KDHE Page 6 of 12 June 15, 2005

BUDGET INSTRUCTIONS: The budget is the organization s plan for expenditures in the Medication Assistance Program (MAP). The budget period should be twelve months for applications due June 30, 2005 and ten months for applications due August 15, 2005. Personnel: Staff Salaries and Benefits Clinical Professional Staff List personnel according to category (e.g. licensed health professional/clinical personnel, clerical, administrative). Beneath the category Clinical Professional Staff each position should be listed separately by title and percent of full-time equivalency (FTE) employed as a health care provider. Allocate the salary amounts to be paid from local organization share and/or State Grant in the appropriate columns. Only regularly assigned personnel who receive salaries or wages should be included in the staff category. Include expenses of payroll taxes and employer-paid benefits. Health professional/clinical staff includes physicians, all nursing personnel (RN, LPN, nursing assistants) nurse practitioners and physicians assistants, or registered pharmacists. Contract Personnel Contract Personnel are health professionals (similar to staff personnel listed above) who provide health care services by special arrangement or contract. The full time equivalency (FTE) of the contracted person shown in the column marked "% time worked in program." Dollar amounts from the appropriate revenue source are listed in the appropriate columns. This category may also be included for payments made for services of a pharmacist. Cost related to the contracted service may not be more than the fair market value. The local health agency s share may not be more than the actual cost of the service contracted. The organization may use the fair market value of volunteer pharmacist services as local match. Prescription Drugs - Pharmaceuticals This category includes expenditures for pharmaceuticals (prescription medications purchased by the clinic or dispensed from the clinic site). Do not include as local match the cost (value) for donated sample medications. For applicants requesting 340B support, the budget narrative should explain the development of the pharmaceutical budget. Capital Equipment Capital Equipment is defined as items costing $500 or more and having a useful life greater than one year. Avoid budgeting for capital equipment with state funds without prior authorization from the program manager. If capital KDHE Page 7 of 12 June 15, 2005

items purchased with local health agency funds are to be credited toward the local match, they must be listed separately. Other (Including Indirect Cost) Itemize other direct costs. Indirect costs or contributions are acceptable only as part of the local match, but the local health agency must submit an annual indirect cost proposal which meets KDHE requirements. Items included in the indirect cost computation cannot be included as direct cost items. Indirect costs may include rent, utilities, general administration, accounting, etc. Budget Summary Place the total of all budget categories in the appropriate columns on the summary sheet. c. Personnel Allocation by Program Any organization applying for MAP funding must complete the form identifying employees, position titles, salary, and time allocation by program. Any organization that has already applied for state funding from KDHE for one or more other programs should submit an amended Personnel Allocation Form and keep a copy for reference. Instructions are on the second page (or back side) of the form. d. Budget Narrative The budget narrative must accompany the Application and Budget. It should include a justification for specific budget items for which grant funds will be used. The narrative may be written in outline form using the budget categories as the heading, for example travel, educational materials, etc. Budget narrative should not be more than 3 pages. e. Program Narrative Each program varies greatly in terms of mission, service area, range of services, client eligibility, and local project goals and objectives. Submit a brief written narrative including the following: Organizational Background Briefly describe the history and current activities of your organization, including your mission, founding date, major programs and working relationships with local community partners. KDHE Page 8 of 12 June 15, 2005

Proposal Details Please answer the following questions: 1. How is your target population currently obtaining needed prescription medication? Is this working well for your clients? 2. Will this grant enable you to implement a new project or expand a current one? 3. What are the desired outcomes of your project? 4. How will you achieve your desired outcomes? 5. How will you track, measure, evaluate and report your activities (outputs) and your outcomes? f. Written agreements If this project relies upon a partner or partners to contribute services, financial or nonfinancial resources, please submit a written memorandum of agreement with the other agency(ies). g. Letters of Support Letters of support are not required but may be submitted to explain working relationships or partnerships. h. Supporting Documents Applicants who are not currently receiving grants through the Community-Based Primary Care Clinic Program are required to include additional supporting documents: List and brief biographical sketches of key project staff; As appropriate to your type of organization (please include only one copy of each) - IRS Letter of Determination - Most recent Audited Financial Statement - IRS Form 990 Limited additional attachments that will be helpful in demonstrating the merit of your proposal (please include only one set of such items). KDHE Page 9 of 12 June 15, 2005

i. Reporting Requirements Financial reports (Expenditure Affidavits) will be required as specified in the contract which will contain the award amount, as well as other terms and conditions. Progress reports and a final project report will include at least the following items: Total count of clinic users by age, insurance status, income, as well as race and ethnicity, if available. Total count of clinic users receiving prescription drugs Total count of prescriptions disbursed or dispensed Percent of clinic users receiving prescription drug assistance by income Total market price (average retail price) of all prescription drugs made available through your organization Total actual cost of all prescription drugs made available through your organization Average retail cost per prescription (if available) Average actual cost per prescription Total of all client prescription drug payments Average client payment for prescription drugs Total value of all discounts for prescription drugs Average discount per prescription Total Count of Clinic Users Total Count of Clinic Users receiving medication assistance Percent Rx Users at or below 10 FPL Percent Rx Users 101% to 20 FPL Percent Rx Users above 20 FPL Total Count of Prescriptions disbursed Total Cost of Prescription drugs Total Market Price (retail value) Total Client payments for Rx Drugs Total value of discounts Average Cost/ Prescription Average Retail Value/ Prescription Average Client payment ($) for Rx Drugs Average discount ($) KDHE Page 10 of 12 June 15, 2005

For evaluation purposes CHCs will be asked for additional information: 1 2 3 4 5 Diagnostic Category: List the top five most common primary diagnostic categories requiring treatment with prescription drugs (see UDS Table 6 items 1 20d); 1 2 3 4 5 Medication Category: List the top five most commonly prescribed medication categories. KDHE PROGRAM CONTACT PERSON: Barbara Gibson, Director, Primary Care Office KDHE Office of Local and Rural Health 1000 SW Jackson, Suite 340 Topeka, KS 66612-1365 phone: (785) 296-1200 fax: (785) 296-1231 email: bgibson@kdhe.state.ks.us Additional information, forms and materials may be found on the KDHE Website at: http://www.kdhe.state.ks.us/olrh/index.html KDHE Page 11 of 12 June 15, 2005

APPENDIX KDHE Page 12 of 12 June 15, 2005

FACE SHEET State of Kansas To be completed by State Office Department of Health & Environment Date Received: Office of Local & Rural Health Curtis State Office Building, Suite 340 Grant Period: Topeka, KS 66612-1365 July 1, 2005 - June 30, 2006 (785) 296-0425 September 1, 2005 June 30, 2006 ------------------------------------------------------------------------------------------------------------------------------------------- APPLICATION FOR GRANT ------------------------------------------------------------------------------------------------------------------------------------------- Application Checklist: Applicant (Name of Agency) YES Not Applicable Grant Budget Budget Narrative Street Address Program Narrative Universal Contract City Zip Code Attachment DA146a SFY2006 Personnel Allocation by Program Name of Director/Chief Executive Officer GRANT FUNDS REQUESTED Email Address: Medication Assistance Grant $ Telephone: Area Code-Number to Primary Care Clinics Fax: Area Code-Number Fiscal Officer Telephone: if different from Applicant Agency Type of Organization - (Public, Private Non-Profit, FQHC FQHC Look-Alike, Other, please describe) FEIN # Comments: President/Chair of Governing Board Administrator/ExecutiveDirector Date: Date:

APPLICATION FOR GRANT INSTRUCTIONS One completed form is required as the cover sheet for the application GENERAL INFORMATION: Enter the name of your organization or agency, address, telephone number(s), Federal Employee Identification Number (FEIN) and the names of your agency s director/health officer and fiscal officer in the appropriate spaces. In addition, indicate whether your agency is a federally qualified health center (FQHC), FQHC Look-Alike, not-forprofit agency and the area (e.g. city(ies), county or counties) where your program will be conducted in the appropriate spaces. APPLICATION CHECKLIST: Indicate here those items that are included in your application packet. GRANT FUNDS REQUESTED: Enter here the amount of GRANT funds being requested from KDHE, on the appropriate line. Please do NOT include matching or other local funds. SIGNATURES: The Application must be signed by both the President/Chairman of the Local Governing Board AND the Administrator/Director of the local agency.. COMMENTS: This section should be used to explain or clarify your funding requests. PROGRAM REQUEST FORMS and DETAILED BUDGET FORMS should be completed according to Grant Application Guidelines and included with this cover sheet.

State of Kansas Department of Health & Environment Office of Local & Rural Health Curtis State Office Building, Suite 340 Topeka, KS 66612-1365 To be completed by State Office Date Received: Grant Period: (785) 296-0425 September 1, 2005 June 30, 2006 ------------------------------------------------------------------------------------------------------------------------------------------- NOTICE OF INTENT TO APPLY FOR GRANT FUNDS ------------------------------------------------------------------------------------------------------------------------------------------- TOTAL GRANT FUNDS TO BE REQUESTED Medication Assistance Grant to Primary Care Clinics $ Project may include one or more of the following. Please check those for which you are eligible and plan to apply: Section 340B Program implementation or formulary expansion * Subsidy for 340B sliding scale discounts* Support for health professional staff to disburse 340B prescription medications* Support for staff to coordinate Medication Assistance Programs (Manufacturers Indigent Drug Programs) * Eligibility restricted to Federally Qualified Health Centers (FQHC) and FQHC Look-Alikes Applicant (Name of Agency) Street Address Type of Organization - (Public, Private Non-Profit, FQHC FQHC Look-Alike, Other, please describe): City Zip Code Name of Director/Chief Executive Officer In which cities or counties will access to prescription medication be expanded with help from this grant? Email Address: Telephone: Area Code-Number Fax: Area Code-Number Comments: Administrator/Executive Director or President/Chair of Governing Board Date

INSTRUCTIONS FOR NOTICE OF INTENT TO APPLY Program applicants who are unable to submit a completed grant application by June 30, 2005, [for the 12-month funding period 7/1/05-6/30/06] are required to complete of this form. Completion of this form is required in order to be considered for grant funds for the 10-month period September 1, 2005 June 30, 2006. Submission of this form will indicate your intent to submit a complete grant application before the August 15, 2005 deadline. Organizations with applications submitted on or before the June 30 deadline need not submit this form. All necessary information will be obtained from the Face Sheet of the application. GENERAL INFORMATION: Enter the name of your organization or clinic organization or agency, contact information, and the names of your clinic or health center director and fiscal officer in the appropriate spaces. In addition, indicatewhether your agency is a federally qualified health center (FQHC), FQHC Look-Alike, or not-for-profit agency and the area (e.g. city(ies), county or counties) where your program will be conducted in the appropriate spaces. GRANT FUNDS REQUESTED: Enter here the amount of GRANT funds being requested from KDHE, on the appropriate line. Please do NOT include matching or other local funds. SIGNATURES: The Notice of Intent to Apply may be signed by either the President/Chairman of the Local Governing Board or the Administrator/Director of applicant organization. COMMENTS: This section may be used to briefly describe your proposal.

Initial Application [ ] BUDGET -- PLAN FOR EXPENDITURES: MEDICATION ASSISTANCE PROGRAM (MAP) Revised Budget [ ] SFY2006: Detailed Budget for Grant Funds (See instructions page 7) Attach additional sheet(s) as necessary Expenditure Classification PERSONNEL Clinical - Professional Staff Staff Personnel (List each health professional position) Salary for Grant Period July 1, 2005 to June 30, 2006 Clinic Name: FTE(%) Worked in MAP Local Applicant Share of Expense Actual Expense Non-Cash Donation: In-Kind Contribution State Grant Request Total Expense Administrative Assistants Other Administrative FICA (7.65%) Retirement ( ) Other: ( ) CONTRACT PERSONNEL (List each health professional position) PERSONNEL CATEGORY TOTAL

Local Applicant Share of Expense Expenditure Classification Actual Expense Non-Cash Donation: In-Kind Contribution State Grant Request Total Expense PRESCRIPTION DRUGS PRESCRIPTION DRUG CATEGORY TOTAL CAPITAL EQUIPMENT (consult with program officials and avoid, if possible) CATEGORY TOTAL OTHER DIRECT EXPENSES (ITEMIZE) CATEGORY TOTAL TOTAL EXPENDITURES BUDGET KDHE USE ONLY: Audited By: MAP Budget page 2

OTHER TOTAL % ** SFY 2006 PERSONNEL ALLOCATION BY PROGRAM Medication Assistance Program Attachment DATE: APPLICANT ORGANIZATION: STATE FORMULA #1 CDRR #2 FAM-PLAN #5 ADOL-TEEN PREG #8 ADOL-SCHOOL #9 ADOL-RES MAT #10 AIDS HERR #13 AIDS CO/TEST #14 AIDS INTER & PREV #15 STD INTER #16 MCH #17 CHILD CARE LIC #18 AIDS EN PREV C&T #22 PRIMARY CARE #27 TEEN PREG-PEER ED #28 TEEN PREG-CASE MGT #32 AIDS CASE MGT #33 IAP #34 AIDS GBM #36 OTHER EMPLOYEE NAME POSITION TITLE SALARY * * Annual salary or hourly rate x number of hours worked during year (Full time is estimated as 2080 hours per year) ** Total must not exceed 10

COMPLETION INSTRUCTIONS FOR PERSONNEL ALLOCATION BY PROGRAM SFY 2006 Instructions to complete the SFY 2006 Personnel Allocation by Program Form are as follows. This information must be in agreement with the detailed budget(s) filed with individual Program Attachment(s) in the Aid to Local Grant Application. If new staff will be added or staff time reallocated as a result of Medical Assistance Program application, submit a revised Personnel Allocation Form and retain a copy for your reference. Local Agency/Organization Name - Print or type the name of the organization making the application or receiving an award. Employee Name Position Title - -Identify the employee in the position. You can abbreviate with last name, initials, position number, etc. If the position is vacant or a new position, indicate such by "Vacant", "New", "to be hired", etc., in this column. Identify the position title, e.g. RN 1, RN 2, Clerk, Pharm Asst, etc. Abbreviate any title as needed Salary - Report the annual salary based on full time equivalency. If a different basis is used, specify what you are basing the salary on. For example, if an employee is paid hourly, indicate the hourly rate times the number of hours per year. (Example: $5.00/hr X 2,080 hours) Program Titles - List the specific % time worked under the appropriate program title(s). Other - Identify what Program(s) the employee is reported working on, if the program is not one previously reflected. Total - Total must not exceed 10 for any employee. Use additional pages as necessary. Salaries and percent of time worked should be rounded to the nearest whole figure. Footnote any discrepancies or clarify what is being reflected. All budgets submitted must be in agreement. If you have questions while completing this form, please contact Kevin Shaughnessy (785) 296-1507, Internal Management/Accounting Services.