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Getting HIV Drugs in the U.S.

October 26, 2014

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Medicaid is a government-sponsored insurance program that covers healthcare and medications. If you are disabled, not working, or earning little money, you may qualify for Medicaid. Like ADAP, each state has its own program so you will need to talk to a local Medicaid worker in order to apply. The ACA will enable states to provide access to Medicaid for people living below 138 percent of the federal poverty level. It is important to note that only some states have chosen to expand their Medicaid coverage and change their eligibility requirements through the ACA; others are still deciding. Many of the states that have decided not to expand Medicaid are also the states where the highest numbers of people living with HIV live.

In addition, Medicaid eligibility will now be determined based on income alone; disability status will no longer be required. It is important to note that only some states have chosen to expand their Medicaid coverage and change their eligibility requirements through the ACA; others are still deciding.



Medicare is a government-sponsored insurance program for people over 65 and those who are disabled (with a work history) or blind. Part D of Medicare pays for medications. The ACA will gradually close the gap in Medicare's prescription drug benefit (Part D) known as the "doughnut hole." The doughnut hole refers to the amount between total drug costs (what you and your plan spend in drugs) and a person's total out-of-pocket spending maximum for the year (this includes any co-pays, co-insurance, and deductibles). In addition, ADAP payments for prescription drugs are now considered contributions toward the True Out of Pocket Spending Limit (TrOOP) for Part D, which means that people can move through the doughnut hole more quickly.

For more information on ADAPs, Medicaid, and Medicare, see the Health Benefits section of The Well Project's Public Benefits and HIV in the US article.

Health Insurance Marketplaces

If you do not have access to insurance offered by an employer or do not qualify for Medicaid, you can look for affordable health insurance through the health insurance marketplaces. These marketplaces for individuals and families are available either through your state, if it chose to set up a marketplace, or through the federal government, if your state chose not to participate. Click here to learn more about enrolling in the federal marketplace.

For those who have trouble paying, there are federal tax credits and subsidies (money the government gives you) for people with low and middle incomes to help make the insurance premium more affordable.

Drug Company Programs

Drug companies run Patient Assistance, Expanded Access, and Compassionate Use Programs. Each company has its own rules for deciding how the program works. Your health care provider will need to complete applications in order for you to apply.

Patient Assistance Programs help people get medications that are already approved by the US Food and Drug Administration (FDA). If you qualify for the program, you will be able to get your HIV drugs without cost. Patient Assistance Programs are usually a short-term solution until another way of paying for the drug is arranged. However, this can be helpful if you are waiting for insurance or government benefits to begin.

Expanded Access and Compassionate Use programs provide drugs that are not yet FDA-approved to people who are in serious risk of illness or who have no other way to construct a good treatment regimen. The drugs are provided free of charge by the companies developing them through participating health care providers.

A company will often create an Expanded Access Program just before the drug is about to be accepted by the FDA. The rules are the same for everyone using the program, while with Compassionate Use Programs, each case is looked at individually.

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This article was provided by The Well Project. Visit The Well Project's Web site to learn more about their resources and initiatives for women living with HIV. The Well Project shares its content with to ensure all people have access to the highest quality treatment information available. The Well Project receives no advertising revenue from or the advertisers on this site. No advertiser on this site has any editorial input into The Well Project's content.

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