THE COST OF
Assistance programs help pay for meds
By Jeff Berry and John Peller
Treatment for HIV is expensive, but the good news is that help is out there! Several non-profit organizations and even the pharmaceutical companies themselves have programs to help you pay for the treatment you need.
Co-pay and Patient Assistance Programs
Most pharmaceutical companies provide some level of assistance through a patient assistance program (PAP) for people who can’t afford their HIV medications. These PAPs are typically for patients without insurance who don’t qualify for Medicare, Medicaid, or ADAP. Qualifications and criteria vary by program and are based on a percentage of Federal Poverty Level (FPL). Patients or providers should contact the program to see if they are eligible (see charts below).
Many companies also have co-pay assistance programs for those who have drug coverage through privately held insurance. These programs may cover all or part of the drug co-pay up to a specified amount. Certain restrictions and eligibility requirements apply (for example, recipients of ADAP, Medicare, and Medicaid are not eligible). Individuals can get the co-pay card directly from their provider, the manufacturer’s website, or by calling a toll-free number. Some programs have a reimbursement process in case you are forced to pay the co-pay out of pocket if the pharmacy can’t or won’t accept the card. And some PAPs will make exceptions; for example, for a person on ADAP who has insurance but who has a high deductible, they may cover a certain percentage. Check with each program for details.
The Affordable Care Act
The Affordable Care Act (ACA, commonly referred to as “Obamacare”) will improve access to coverage for many people with HIV. Although the new law is far from perfect, the ACA’s intention to provide more affordable benefits will allow many people with HIV to address their health needs. Beginning this year, insurers won’t be able to deny coverage to people with HIV/AIDS or impose annual limits on coverage. Low- and middle-income earners may be eligible for tax subsidies to help them buy coverage from health insurance exchanges, or marketplaces. In 26 states that haven’t refused it (as of January 2014), Medicaid eligibility will expand to generally include those under 65 with incomes below 133% of the federal poverty level ($15,282 for an individual; $31,322 for a family of four).
Advocates across the country have raised concerns about the high cost of some HIV drugs available through some exchange plans. Although plans with affordable HIV drug coverage co-pays exist in almost all areas, individuals who select the wrong plan may have to pay $1,000 or more (up to 50%) in co-insurance for HIV drugs for several months out of the year. Make sure you know what your plan will cost in terms of co-insurance and deductibles, as well as the monthly premium. In addition, some plans do not cover all HIV medications. To make sure your drugs are included on the formulary of the plan you choose; have a list of all your meds, for HIV and any other condition, and ask specifically if they are covered.
Fortunately, many state AIDS Drug Assistance Programs (ADAPs) can help pay out-of-pocket costs for HIV drugs obtained through some exchange plans. ADAPs can also help pay premiums in some states. Check with your state ADAP to learn what your state offers, as well as the income limits. If you’re not eligible for ADAP, you may be able to use co-pay cards to make medications more affordable.
It is critical to consult a trained enrollment “navigator,” when choosing an exchange plan. Contact your local HIV/AIDS service organization for help or a referral.
Advocates are pressing for clarity from the administration as to whether or not qualified health plans (QHPs) purchased through a health insurance exchange are considered government programs, which would therefore make policyholders ineligible to receive co-pay assistance. As this issue went to press, several companies have interpreted it this way and are currently excluding people with QHPs from co-pay coverage.
Medicare Part D
The Affordable Care Act provides for closing the Medicare Part D prescription drug benefit “donut hole” by 2020. Beneficiaries receive a 50% discount on covered brand-name drugs while they are in the “donut hole,” with increased savings on prescription drugs while they are in the coverage gap until the gap is fully closed. In addition, ADAP benefits are now considered as contributions toward Medicare Part D’s True Out of Pocket spending limit (“TrOOP”), so ADAP clients who have Medicare Part D should be able to benefit.
Harbor Path and the Common PAP Form
HarborPath is a non-profit organization that helps uninsured people living with HIV/AIDS and/or hepatitis C to gain access to brand-name prescription medicines at no cost, by providing case managers with a single online portal for PAP applications and medication fulfillment through a mail-order pharmacy. Go to harborpath.org.
The Department of Health and Human Services (DHHS), along with seven pharmaceutical companies, the National Alliance of State and Territorial AIDS Directors (NASTAD), and community stakeholders developed a common patient assistance program application that can be used by both providers and patients, instead of filling out different sets of paperwork for each company PAP. To download the form, go to hab.hrsa.gov/patientassistance.
Co-pay and patient assistance programs are also available for hepatitis B and C drugs, and medications or treatments used for other HIV-related conditions such as lipodystrophy—some of these are included in the co-pay and PAP charts at right.
To learn more about patient assistance or co-pay programs for drugs used to treat certain opportunistic infections or other conditions, talk to your provider, contact the manufacturer directly, or go to pparx.org and needymeds.org. SurvivorRxPlan offers help in getting many medications not covered by ADAP, including alternative therapies and generics, even if you receive medicines through another discount program. It is available to individuals with incomes of up to $36,425, and higher based on family size. Go to SurvivorRxPlan.com.
Stay informed and up to date
Keeping the lines of communication open between you and your health care provider, pharmacist, and case manager is essential when managing your health, so stay informed. Use the chart below to check specific details.
John Peller is Interim President/CEO of AIDS Foundation of Chicago.