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Don't Break the Bank: Assistance Programs Can Help Pay for Meds

By Jeff Berry

March/April 2013

Click to view our copay assistance charts:

The charts above give a brief description of many co-pay and patient assistance programs. If you need help, call the Project Inform Hotline at 800-822-7422, or call the number or go to the website listed for each program. Also go to www.positivelyaware.com/copay as details of specific programs may change.

Treatment for HIV is effective yet costly, but it doesn't have to break the bank. Following are ways to help pay for not only your HIV meds, but other drugs commonly used by people with HIV.


Co-Pay and Patient Assistance Programs

Most pharmaceutical companies provide some level of assistance to individuals who are unable to afford their HIV medications by way of a patient assistance program, or PAP. 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 chart).

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). By law, residents of Massachusetts 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. Once enrolled, bring the co-pay card to the pharmacy when filling your prescription. 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.


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The Affordable Care Act

Insurers are no longer able to deny coverage to children living with HIV/AIDS. Insurers also cannot impose lifetime caps on benefits for anyone. The Pre-existing Condition Insurance Plan helps those who have been locked out of the insurance market because of their health status, including those living with HIV/AIDS.

Beginning in 2014, insurers won't be able to deny coverage or impose annual limits on coverage. Low- and middle-income earners will be eligible for tax subsidies to help them buy coverage from state health insurance exchanges. Some states have refused to set up exchanges, so the federal government will do it for them. In states that haven't refused it, Medicaid eligibility will expand to generally include those with incomes below 133% of the Federal poverty line ($15,281 for an individual/$31,321 for a family of four).

The Affordable Care Act also closes, over time, the Medicare Part D prescription drug benefit "donut hole." 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 2020. In addition, AIDS Drug Assistance Program (ADAP) benefits are now considered as contributions toward Medicare Part D's True Out of Pocket Spending Limit ("TrOOP"), so ADAP clients who are Medicare Part D enrollees should now be able to move through the donut hole much more quickly.


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Welvista, Harbor Path and the Common PAP Form

Around one-third of all people receiving HIV treatment in the U.S. get their medications through AIDS Drug Assistance Programs (ADAPs). Welvista is a non-profit organization funded by the Heinz Family Philanthropies and seven pharmaceutical companies. The program facilitates access to HIV meds for those on ADAP waiting lists by streamlining paperwork and using a single mail-order pharmacy, rather than having to access multiple patient assistance programs. Go to www.welvista.org.

Two other recent developments that will potentially ease access to PAPs are the Common PAP Form and HarborPath. 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. Before, patients and advocates had to fill out different sets of paperwork for each company PAP -- the new application should help simplify this process. Go to http://hab.hrsa.gov/patientassistance to download the form.

HarborPath is a non-profit organization that helps uninsured individuals living with HIV/AIDS gain access to brand-name prescription medicines at no cost, by providing case managers with a single "one-stop shop" online portal for PAP applications and medication fulfillment through a mail-order pharmacy. Currently in its pilot phase in five states with two pharmaceutical companies on board, it hopes to expand in 2013, including adding medicines for hepatitis C. Go to www.harborpath.org.


Additional Programs

Co-pay and patient assistance programs are also available for drugs used to treat hepatitis B and C, and medications or treatments used for other HIV-related conditions such as lipodystrophy. This year for the first time we are including some of these in the co-pay and PAP chart (see chart).

To learn more about patient assistance or co-pay programs for drugs used to treat certain opportunistic infections or other conditions such as high cholesterol and diabetes, talk to your provider, contact the manufacturer directly, or go to www.pparx.org and www.needymeds.org.

Together Rx Access is a prescription savings program for uninsured individuals; call 800-966-0407, or enroll online at www.TogetherRxAccess.com.

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 www.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. In some cases, your health care provider may not be aware of all the programs available, so visit our co-pay charts to check specific details.

Special thanks to the Fair Pricing Coalition for some of the information contained in this article. The Fair Pricing Coalition (FPC) regularly meets with drug companies on pricing and access issues. [Note: The author is a member of the Fair Pricing Coalition.] Go to www.fairpricingcoalition.org.




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