Knowing Where to Look: Finding Assistance Programs to Help Pay for Your Meds

Today's therapies are vastly improved over the first drugs used to treat HIV, but these advancements continue to come at a cost. The prices of HIV drugs continue to rise every 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. ADAPs, 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 certain medications. These PAPs are typically for patients without insurance who don't qualify for Medicare, Medicaid, or AIDS Drug Assistance Programs (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, and don't have any income requirements. 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 in place if you are required 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 (ACA) has improved access to coverage for many people with HIV or vulnerable to HIV. Although the law is far from perfect, the ACA's intention to provide more affordable benefits will allow people with HIV to address their health needs. The law also provides access to pre-exposure prophalyxis (PrEP), medication 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 many states to generally include those under 65 with incomes up to 138% FPL.

Advocates have raised concerns about the high cost of some HIV drugs available through certain exchange plans. 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.

Many state 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 medication 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 $7,500 a year. 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/index.php/en/patients/how-to-apply.

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

Special thanks to Britten Pund, Associate Director of Health Access, NASTAD, for her review of this article; Jason Lancaster for updating the accompanying chart; 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.]

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Drug

Company

Co-Pay Program

Patient Assistance

Details

Aptivus

Boehringer Ingelheim

None

800-556-8317;

rxhope.com or pparx.org

Patient assistance program only.

Atripla

Gilead Sciences

877-505-6986;

gileadadvancingaccess.com

866-290-4767

Co-pay program covers up to $6,800 per year with no monthly limit. 

Combivir

ViiV Healthcare

None

877-784-4842;

viivhealthcareforyou.com

No co-pay card; generic available. Patient assistance program only.

Complera

Gilead Sciences

877-505-6986;
gileadadvancingaccess.com

800-226-2056;

gileadadvancingaccess.com

Co-pay program covers up to $6,000 per year with no monthly limit.

Crixivan

Merck & Co.

None.

800-652-3430;

merckhelps.com

Patient assistance program only.

Edurant

Janssen Therapeutics

866-961-7169;

edurant.com; jtsavings.com

800-652-6227;

jjpaf.org

Co-pay program covers up to $7,500/year with no monthly limit. Card available through provider or at jtsavings.com.

Emtriva

Gilead Sciences

877-505-6986;

gileadadvancingaccess.com

800-226-2056;

gileadadvancingaccess.com

Card available through your provider, AIDS service organization, and pharmacy. Co-pay program covers up to $3,600 per year with a monthly maximum of $300.

Epivir

ViiV Healthcare

None

877-784-4842;

viivhealthcareforyou.com

No co-pay card; generic available. Patient assistance program only.

Epzicom

ViiV Healthcare

866-747-1170;
mysupportcard.com

877-784-4842;

viivhealthcareforyou.com

Card available online or through provider. Co-pay program covers
up to $2,400 per year with no monthly limit.

Evotaz

Bristol-Myers Squibb

888-281-8981;
bms3assist.com

888-281-8981;

bms3assist.com

Co-pay program covers up to $7,500 per year with no monthly limit.

Fuzeon

Genentech

None

pparx.com

Patient assistance program only.

Genvoya

Gilead Sciences

877-505-6986;

gileadadvancingaccess.com

800-226-2056;

gileadadvancingaccess.com

Co-pay program covers up to $6,000 per year with no monthly limit.

Intelence

Janssen Therapeutics

866-961-7169;

intelence.com; jtsavings.com

800-652-6227;

jjpaf.org

Co-pay program covers up to $7,500/year with no monthly limit.
Card available through provider or at jtsavings.com.

Invirase

Genentech

None

pparx.org

Patient assistance program through pparx.org.

Isentress

Merck & Co.

isentress.com

800-850-3430;

merckhelps.com

Co-pay program covers up to $6,600 per year per prescription.

Kaletra

AbbVie, Inc.

866-525-3872; kaletra.com

800-222-6885; abbviepaf.org

Co-pay program covers up to $400 per month per prescription.

Lexiva

ViiV Healthcare

866-747-1170, option 5;
mysupportcard.com

877-784-4842;

viivhealthcareforyou.com

Co-pay program covers up to $2,400 per year with no monthly limit.

Norvir

AbbVie, Inc.

800-441-4987;
norvir.com

800-222-6885;
abbviepaf.org

Co-pay program covers up to $100 per month per prescription.

Prezcobix

Janssen Therapeutics

866-961-7169;

prezcobix.com; jtsavings.com

800-652-6227;

jjpaf.org

Co-pay program covers up to $7,500/year with no monthly limit.
Card available through provider or at jtsavings.com.

Prezista

Janssen Therapeutics

866-961-7169;

prezista.com; jtsavings.com

800-652-6227;

jjpaf.org

Co-pay program covers up to $7,500/year with no monthly limit.
Card available through provider or at jtsavings.com.

Rescriptor

ViiV Healthcare

866-747-1170;
mysupportcard.com

877-784-4842;

viivhealthcareforyou.com

No co-pay card; generic available. Patient assistance program only.

Retrovir

ViiV Healthcare

None

877-784-4842;

viivhealthcareforyou.com

No co-pay card; generic available. Patient assistance program only.

Reyataz

Bristol-Myers Squibb

888-281-8981;

bms3assist.com

888-281-8981;

bms3assist.com

Co-pay program covers up to $7,500 per year with no monthly limit.

Selzentry

ViiV Healthcare

866-747-1170;
mysupportcard.com

877-784-4842;

viivhealthcareforyou.com

Co-pay program covers up to $2,400 per year with no monthly limit.

Stribild

Gilead Sciences

877-505-6986;

gileadadvancingaccess.com

800-226-2056;

gileadadvancingaccess.com

Co-pay program covers up to $6,000 per year with no monthly limit.

Sustiva

Bristol-Myers Squibb

888-281-8981;
bms3assist.com

888-281-8981;
bms3assist.com

Co-pay program covers up to $7,500 per year with no monthly limit.

Tivicay

ViiV Healthcare

866-747-1170;
mysupportcard.com

877-784-4842;

viivhealthcareforyou.com

Co-pay program covers up to $6,000 per year with no monthly limit.

Triumeq

ViiV Healthcare

866-747-1170;
mysupportcard.com

877-784-4842;

viivhealthcareforyou.com

Co-pay program covers up to $6,000 per year with no monthly limit.

Trizivir

ViiV Healthcare

None

877-784-4842;

viivhealthcareforyou.com

No co-pay card; generic available. Patient assistance program only.

Truvada

Gilead Sciences

877-505-6986;

gileadadvancingaccess.com

800-226-2056;

gileadadvancingaccess.com

Co-pay program covers up to $3,600 per year with no monthly limit.

Tybost

Gilead Sciences

877-505-6986;

gileadadvancingaccess.com

800-226-2056;

gileadadvancingaccess.com

Co-pay program covers up to $600 per year with a monthly maximum of $50.

Videx EC

Bristol-Myers Squibb

None

pparx.org

No co-pay card; generic available. Patient assistance program through pparx.org.

Viracept

ViiV Healthcare

866-747-1170;
mysupportcard.com

877-784-4842;

viivhealthcareforyou.com

Co-pay program covers up to $2,400 per year with no monthly limit.

Viramune XR

Boehringer Ingelheim

None

pparx.org

No co-pay card for Viramune; available as generic.

Patient assistance program through pparx.org.

Viread

Gilead Sciences

877-505-6986;

gileadadvancingaccess.com

800-226-2056;

gileadadvancingaccess.com

Co-pay program covers up to $3,600 per year with a monthly maximum of $300.

Zerit

Bristol-Myers Squibb

None.

pparx.org

No co-pay card; generic available. Patient assistance program through pparx.org.

Ziagen

ViiV Healthcare

None

877-784-4842;

viivhealthcareforyou.com

No co-pay card; generic available. Patient assistance program only.

Drug

Company

Co-Pay Program

Patient Assistance

Details

Truvada for PrEP


Gilead Sciences

877-505-6986;

gileadadvancingaccess.com

800-226-2056;

gileadadvancingaccess.com

For HIV-negative individuals to prevent HIV. Truvada for PrEP Medication Assistance Program (MAP) covers co-pays up to $3,600/year with no monthly cap (additional support considered on case-by-case basis -- call number); for uninsured provides free drug for those with incomes below 500% FPL.


Drug / ASSAY

Company

Co-Pay Program

Patient Assistance

Details

Androgel  (testosterone gel 1% & 1.62%)
For adult males with low or no testosterone

AbbVie, Inc.

855-243-5162;

androgel.com

800-222-6885:

abbviepaf.org;

pparx.org

Co-pay: Patient pays first $10, then covers up to $100 per month for a total of 12 transactions. Card available through provider or print the card online.

Axiron (topical liquid testosteronel solution
30 mg/1.5 mL) For adult males with low or
no testosterone

Eli Lilly and Company

877-929-4766;

axiron.com

855-559-8783;

lillycares.com

Co-pay: First month free, then $25 to $75 per month. Card available online. Free 30-day sample through Axiron representative.

Egrifta Injectable for treating HIV-related excess belly fat (lipohypertrophy)

Theratechnologies

844-347-4382;

egrifta.com

844-347-4382;

egrifta.com

Call number or go to egrifta.com for program details.

Fortesta (testosterone gel 2%) For adult males who have low or no testosterone)

Endo Pharmaceuticals

800-462-3636;

fortestagel.com

None.

Co-pay amount depends on the type of patient's insurance (commercial vs. government vs. no insurance).

Fulyzaq Anti-diarrheal approved for use in those with HIV/AIDS and on antiretroviral therapy.

Salix Pharmaceuticals

None

866-282-6563;

salix.com

No co-pay program, PAP only. Appeals process in place for PAP, may possibly help with co-pay, apply second time if turned down initially. Go to cdn.salix.com/fulyzaq/assets/pdf/fulyzaq-patient-assistance-program-application.pdf

HLA-Aware HLA-B*5701 test to determine if a person can start taking Ziagen, Epzicom, Trizivir, or Triumeq

LabCorp/
ViiV Healthcare

viivhcdxresource.com

877-844-8872;

viivhcdxresource.com/HLA/AwareProgram

Covers entire cost of test for insured/uninsured. Test must be ordered by provider. Contact local ViiV rep, order online, or call.

Natesto (testosterone) nasal gel

For adult males with low or no testosterone

Endo Pharmaceuticals

844-NATESTO (628-3786);
natesto.com

None.

No PAP. Co-pay: Patient pays first $25, then up to
$150 per prescription.

Procrit

Treats anemia due to zidovudine therapy

Janssen Pharmaceuticals

None

800-652-6227;

jjpaf.org

No co-pay program, PAP only. Medicare Part D Extra Help with Low-Income Subsidy available: secure.ssa.gov/i1020/start

Radiesse

Injectable facial filler approved for use in people with HIV to treat facial fat loss (lipoatrophy)

Merz Aesthetics

None

866-862-1211;

radiesse.com

No co-pay program. PAP is sliding scale based on patient's annual income up to $50,000; reimbursement goes directly to physician.

Sculptra

Injectable facial filler approved for use in people with HIV to treat facial fat loss (lipoatrophy)

Valeant Pharmaceuticals International

None

866-310-7551;

needymeds.org

No co-pay program. PAP provides two kits and one follow-up kit. Free for those with an annual income below $22,340, and then on a sliding scale up to $61,940.

Serostim

Injectable human growth hormone used for treating HIV-associated wasting in those on ART

EMD Serono

877-714-2947;

serostim.com

877-714-2947;

serostim.com; 866-962-1128

Co-pay program covers up to $1,500 per prescription with a maximum of 12 discounts per lifetime.

Trofile Assay

A test to determine the tropism of a person's HIV to see if a CCR5 antagonist (such as Selzentry) would be effective

Monogram Biosciences

None

877-436-6243;

monogrambio.com;
viivhcdxresource.com/HLA/AwareProgram

Gateway coverage for uninsured / underinsured; assists in prior authorization or if insurance reimbursement is denied. ViiV also has Tropism Access Program (TAP) for ADAP eligible; see website, or contact state ADAP.

Vogelxo (testosterone gel 1%)

For adult males with low or no testosterone

Upsher-Smith Laboratories, Inc.

None

None

A 30-day free trial card available online.