POSITIVELY AWARE March/April 2012
Editor's Note - Keeping the Faith
Let’s face it, HIV medications are expensive, even for those with health insurance. Fortunately, financial assistance is available to help cover some, if not all, of the costs associated with treating HIV. The last thing anyone 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
Most pharmaceutical companies provide some level of assistance to individuals who are unable to afford their HIV medications, through the use of a 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%. 100% of FPL is currently $10,890 for a single individual, so 300% would be $32,670. Some 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).
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 (FPC) regularly meets with drug companies on pricing issues and in an effort to help control costs and improve access to these life-saving medications. The existing HIV and hepatitis drug co-pay programs are the direct result of ongoing discussions between the 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 basic medical and preventive services, 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.
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. Welvista is a non-profit organization funded by the Heinz Family Philanthropies and through grants from many of the major pharmaceutical companies. Currently, seven 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.
This past year several pharmaceutical companies continued to expand coverage for their co-pay and patient assistance programs, and provided additional cost rebates to AIDS Drug Assistance Programs (ADAPs) around the country. However, budget cuts continue to hit ADAPs hard, and many states have continued to slash formularies, cap enrollment, and institute waiting lists, among other harsh measures.
People living with HIV/AIDS may need medications for other 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 for uninsured individuals; call toll-free 800-966-0407, or enroll online at www.TogetherRxAccess.com.
SurvivorRxPlan offers help to get many medications not covered by ADAP, including alternative therapies and generics. Patients can use the program even if they receive medicines through another discount program. It is available to individuals with incomes of up to $36,425, and higher based on family size. 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. For example, Egrifta, used to treat lipohypertrophy, has a co-pay program and a PAP; and Sculptra, which is used to treat facial lipoatrophy, has a PAP which provides the facial filler for free or on a sliding scale. Contact the manufacturer, discuss with your provider, or visit www.fairpricingcoalition.org.
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 use the adjacent chart to check specific details for all HIV drug programs. You can also visit www.positivelyaware.com for the most current information, as details of specific programs may change.
Special thanks to the Fair Pricing Coalition for some of the information contained in this article. Note: The author is a member of the Fair Pricing Coalition.