Accessing expensive medications is an art
Positively Aware Jeff Berry
By Jeff Berry @paeditor

Today’s therapies are vastly improved over the first drugs used to treat HIV, but these advancements have come at a cost. The prices of HIV drugs continue to rise year after year at an average of 7–9 percent. While in the past this usually hasn’t directly affected someone who has drug coverage through their health insurance plan, increasingly individuals are having to pay co-insurance (a percentage of the cost) on their medications. The good news is that help is out there. Several non-profit organizations and the pharmaceutical companies themselves have assistance programs in place 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 for treatment or prevention. 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).

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, co-insurance, and deductibles up to a specified amount. Certain restrictions and eligibility requirements apply (for example, recipients of ADAP, Medicare, and Medicaid may not be 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 if you have to pay the co-pay out of pocket. 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. Be sure to ask for an exception or review if you are at first denied.

The Affordable Care Act

Commonly referred to as “Obamacare,” the Affordable Care Act has already improved access to coverage for many people with HIV or at risk of 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. The law also provides access to pre-exposure prophalyxis (PrEP), medications to prevent HIV. Insurers can no longer 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. Medicaid eligibility has now expanded in 28 states to generally include those under 65 with incomes up to 133% of the Federal Poverty Level.

Advocates have raised concerns about the high cost of some HIV drugs available through certain exchange plans. According to an article by Michael Ruppal in the December 2014 issue of HIV Specialist, The AIDS Institute and others sent a letter in July 2014 to HHS Secretary Sylvia Mathews Burwell. In it they “pointed to limited benefits, high cost-sharing, and a lack of transparency on the part of some plans, all of which create barriers to accessing quality healthcare.” Although plans with affordable HIV drug coverage co-pays exist in almost all areas, some plans may require you to pay $1,000 or more (up to 50%) in co-insurance for HIV drugs. Make sure you know what your plan will cost in terms of co-insurance, deductibles, and the monthly premium. In addition some plans do not cover all HIV medications, or price them in the highest tier, including generics. According to Ruppal, transparency improved for 2015 enrollment, but “issues of limited benefits and high-cost sharing may have to wait for further action by HHS.” A ruling is expected soon.

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.

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.

Medicare Part D

The Affordable Care Act provides for closing the Medicare Part D prescription drug benefit “donut hole” or coverage gap 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.

HarborPath 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. To download the form, go to hab.hrsa.gov/patientassistance.

Additional programs

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. There is even a separate assistance program for Truvada as prevention, or PrEP (pre-exposure prophylaxis).

The Patient Assistance Network Foundation recently expanded eligibility criteria for HIV treatment and prevention (including PEP and PrEP). Those who qualify (you must have insurance and income below 500% FPL) are eligible to receive a grant of up to $4,000/yr. to help cover out-of-pocket costs for meds. You may apply for a second grant during your eligibility period depending on available funding. Go to panfoundation.org/hiv-treatment-and-prevention.

To learn more about other patient assistance or co-pay programs for drugs used to treat HIV, certain opportunistic infectionsor 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. 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 adjacent chart to check specific details, or go to positivelyaware.com/copay for the most current information.

Special thanks to Drew Halbur, BSPharm, AAHIVP, BCACP, and his team at Walgreens for updating the accompanying chart; thanks to John Peller, CEO of AIDS Foundation Chicago, and the Fair Pricing Coalition (FPC) for some of the information in this article. Go to fairpricingcoalition.org or hivhealthreform.org. [Note: author is a member of the FPC.]