POSITIVELY AWARE MARCH/APRIL 2011
It’s in the cards
Where to get help to pay for your meds
by Jeff Berry
There are a number of ways to get assistance in paying for your HIV medications depending on your financial situation and the coverage you may or may not currently have.
The good news is that in 2010 many pharmaceutical companies expanded coverage for their co-pay and patient assistance programs. The bad news is that financially strapped AIDS Drug Assistance Programs (ADAPs) around the country had to make some tough decisions just to stay afloat. They did this in some cases by reducing formularies, capping enrollment, and instituting waiting lists, among other strict measures.
The last thing anyone with HIV needs to worry about is not being able to pay for their medications, so hopefully this article will help you to navigate the system and keep your medicine chest full, while keeping your stress level to a minimum.
Co-pay and Patient Assistance Programs
All pharmaceutical companies provide some level of assistance to individuals who are unable to afford their HIV medications through the use of their patient assistance program, or PAP. These PAPs are typically for patients without insurance and 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), for example 300%. The FPL is currently $10,830 for a single individual, so 300% would be $32,490. Some of the companies are now covering up to 500% FPL and even higher, so check the details of each program. Patients or providers should contact the manufacturer directly to see if they are eligible (see chart, next page).
Many companies also have co-pay assistance programs which are designed 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, and for a pre-determined period of time (for example, up to one year). Certain restrictions and eligibility requirements apply (for example, recipients of ADAP, Medicare, and Medicaid are not eligible), and may vary from program to program. Individuals usually get the co-pay card directly from their provider, the manufacturer’s website, or by calling a toll-free number. Once enrolled, they bring the co-pay card to the pharmacy when filling their prescription and the pharmacy is reimbursed for the amount covered.
The Fair Pricing Coalition, founded by the late HIV treatment advocate Martin Delaney, regularly meets with drug companies on pricing issues and in an effort to help control costs and improve access to life-saving medications. The existing HIV and hepatitis drug co-pay programs are the direct result of ongoing discussions between the Fair Pricing Coalition (FPC) and representatives of the pharmaceutical industry. After concerns were voiced by both the FPC and members of the community over rising costs and people not being able to get their medications, many companies increased coverage for their co-pay programs, raised the qualifying level of income for some PAPs and eased restrictions, thereby making the programs even more accessible to people who in the past may not have qualified.
Medicare and Medicaid
Medicare is a federally-funded program focusing primarily on the older population. It is a social insurance program for people age 65 or older, people under age 65 with certain disabilities, including HIV/AIDS, and people of all ages with end stage renal disease. Medicare Part A covers hospital bills, Medicare Part B covers medical insurance coverage, and Medicare Part D covers prescription drugs. Medicare operates similar to a single-payer health care system, the key difference being that its coverage only extends to 80% of any given medical cost; the remaining 20% must be paid by other means, such as privately-held supplemental insurance, or by the patient.
Medicaid is a program that is not entirely funded at the federal level—states provide up to half of the funding, and counties also contribute funds in some states. Eligibility is determined largely by limited income and financial resources. Medicaid covers a wider range of health care services than Medicare, and it is currently the largest single payer for prescription drugs.
To find out if you are eligible, talk to your health care provider or case manager, or contact your state’s Medicare or Medicaid agency.
ADAP and Welvista
Around one-third of all people receiving HIV treatment in the U.S. get their medications through AIDS Drug Assistance Programs (ADAPs), which are a set of federal- and state-funded programs in each state that provide medications to low income patients. To find out if you may qualify or for more information, talk to your health care provider, contact your local AIDS service organization or case manager, or call your state AIDS hotline.
The Welvista program is a non-profit organizarion funded by the Heinz Family Philanthropies and through grants from many of the major pharmaceutical companies. Currently, six companies that market HIV drugs are participating in the program, which is designed to facilitate 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. You will need to be certified by your state ADAP and on a waiting list to participate in this program.Welvista is a stand-alone non-profit company that dispenses medicines for other disease states, not just HIV. Visit www.welvista.com.
Additional programs
There may also be other medications that individuals need for conditions such as high cholesterol or diabetes. To learn more about patient assistance or drug co-pay programs for these and other medications talk to your provider, contact the manufacturer directly, or visit www.pparx.org or www.needymeds.org. Together Rx is a prescription savings program for uninsured individuals sponsored by many of the nation’s leading pharmaceutical companies; call toll-free 800-966-0407, or enroll online at www.TogetherRxAccess.com.
SurvivorRxPlan is for those who qualify financially to help them get many of the medications not covered by ADAP, including alternative therapies and generics. Patients can take advantage of the program even if they receive medicines through another discount program, and it is available to individuals with incomes of up to $36,425.
Visit www.SurvivorRxPlan.com.
Additional co-pay and patient assistance programs are available for drugs used to treat hepatitis B and C, as well as medications or treatments used for other HIV-related conditions such as lipodystrophy; contact the manufacturer, discuss with your health care provider, or visit www.fairpricingcoalition.org for a complete list.
Egrifta assistance
The recently approved Egrifta (tesamorelin), which is used to treat lipohypertrophy, or increased abdominal fat in people with HIV, has a planned co-pay and patient assistance program which is scheduled to launch in early 2011; visit www.egrifta.com. You must get the card from your provider, or you can call 877-714-2947 for details.
Special thanks to David Evans and the Fair Pricing Coalition for some of the information contained in this article. Note: The author is a member of the Fair Pricing Coalition.
This chart gives a brief description of currently available HIV co-pay and patient assistance programs. If you have a problem accessing or using a specific program, call the Project Inform Hotline at 800-822-7422, or call the number listed for each program. Visit www.PositivelyAware.com for more information as details of specific programs may change.
