Today’s therapies are vastly improved over the first drugs used to treat HIV, but these advancements 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 these increases usually haven’t directly affected someone who has drug coverage through their health insurance plan, increasingly individuals have to pay co-insurance (a percentage of the cost of the medication). The good news is that help is out there. ADAPs, several non-profit organizations, and the pharmaceutical companies have assistance programs in place to help you pay for the treatment you need.
The bad news is that changes may be on the way for consumers, as some big health insurers no longer allow the amount of the co-pay cards to be applied towards their deductible or out-of-pocket maximum, or steer them towards other cost-containing measures such as step therapy or individual generics that break up an STR.
A cost-sharing assistance program (CAP) is a program operated by pharmaceutical companies to offer cost-sharing assistance (including deductibles, co-payments and co-insurance) to people with private health insurance to obtain HIV drugs at the pharmacy.
A patient assistance program (PAP) is a program run through pharmaceutical companies to provide free or low-cost medications to people with low-incomes who do not qualify for any other insurance or assistance programs, such as Medicaid, Medicare, or AIDS Drug Assistance Programs (ADAPs). Each individual company has different eligibility criteria for application and enrollment in their patient assistance program.
HarborPath, a non-profit organization that helps uninsured individuals living with HIV gain access to brand-name prescription medicines at no cost, operates a special patient assistance program for individuals on ADAP waiting lists. An individual is eligible for the HarborPath ADAP waiting list program only if he or she has been deemed eligible for ADAP in his or her state and is verified to be on an ADAP waiting list in that state.
Applying for PAPs
IN 2012, 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 form that can be used by both providers and patients. This form combines common information collected on each individual companies form to allow individuals to fill out one form. Once the form is completed, case managers or individuals then submit the single form to each individual company, reducing the overall amount of paperwork necessary to apply for a patient assistance program.
HarborPath operates as a streamlined, online portal for PAP access. HarborPath creates a single place for application and medication fulfillment. This “one stop shop” portal provides a streamlined, online process to qualify individuals and deliver the donated medications of the participating pharmaceutical companies through a mail-order pharmacy.
Special thanks to NASTAD’s Britten Pund and Amanda Bowes for much of the information listed here and to Tim Horn for his review. Adapted from HIV Pharmaceutical Company HIV Patient Assistance Programs and Cost-Sharing Assistance Programs: bit.ly/1XIahvN
|
DRUGS COVERED |
MANUFACTURER & CONTACT INFORMATION |
ASSISTANCE |
RENEWAL |
|
Kaletra and Norvir |
AbbVie 800-441-4987, option 5; |
Kaletra: Co-payment assistance covers the first $400 per prescription per month. Norvir: Covers up to $1,200 a year for co-payments. |
Reapply each year |
|
Evotaz, Reyataz, |
Bristol-Myers Squibb |
Evotaz, Reyataz, and Sustiva: Up to $7,500 annually for co-payments, deductibles, and co-insurance in all commercially-insured plans. |
Reapply each year |
|
Atripla, Biktarvy, Complera, Descovy, Emtriva, Genvoya, Odefsey, Stribild, Truvada, and Tybost |
Gilead Sciences 877-505-6986; |
Genvoya: Covers the first $7,200 per year of co-payments. Atripla, Complera, Odefsey, and Stribild: Covers the first $6,000 per year of co-payments. Descovy and Truvada: Covers the first $4,800 per year of co-payments. |
Reapply each year |
|
Edurant, Intelence, Prezista, and Prezcobix |
Janssen Therapeutics |
Covers the first $7,500 per year of co-payments, deductibles, and co-insurance. |
Reapply each year |
|
Isentress |
Merck and Co. |
Covers the first $6,800 per year of co-payments, deductibles, and co-insurance for each of 12 eligible prescriptions. |
Enrollment is valid until coupon expires |
|
Juluca, Lexiva, Rescriptor, Selzentry, Tivicay, Triumeq, |
ViiV Healthcare |
Juluca, Tivicay and Triumeq: $6,000 per year/per patient maximum. Lexiva, Rescriptor, Selzentry and Viracept: $2,400 per year/per patient maximum. |
Automatic renewal |
|
Invirase |
Patient Access Network Foundation 866-316-7263; |
Maximum benefit is $3,600 per year. Patients may apply for a second grant during their eligibility period subject to availability of funding. |
Reapply each year |
|
DRUGS COVERED |
MANUFACTURER AND CONTACT INFORMATION |
FINANCIAL ELIGIBILITY |
|
Kaletra, Norvir |
AbbVie 800-222-6885; |
Kaletra: 500% FPL |
|
Aptivus, Viramune XR |
Boehringer Ingelheim 800-556-8317; rxhope.com; pparx.org |
500% FPL |
|
Evotaz, Reyataz, and Sustiva |
Bristol-Myers Squibb 888-281-8981; |
300–500% FPL |
|
Atripla, Complera, Descovy, Emtriva, Genvoya, Odefsey, |
Gilead Sciences* 866-290-4767; |
500% FPL |
|
Edurant, Intelence, |
Janssen Therapeutics 800-652-6227; jjpaf.org |
300% FPL |
|
Crixivan, Isentress, |
Merck and Co. 800-727-5400; |
500% FPL |
|
Combivir, Epivir, Epzicom, Lexiva, Juluca, Rescriptor, Retrovir, Selzentry, Tivicay, Triumeq, |
ViiV Healthcare 844-588-3288; |
500% FPL |
* Patients who are insured and who do not meet their payer’s coverage criteria are no longer eligible for support via Gilead’s patient assistance program. This includes clients whose insurer has limited access based on: step-therapy or clinical criteria (e.g., drug and alcohol testing).
Pre-exposure prophylaxis (PrEP) is the use of antiretroviral (ARV) medication to prevent possible HIV transmission with HIV-negative individuals who may be at higher risk of infection. PrEP is currently recommended for sexually active men who have sex with men (MSM), heterosexual men and women, and intravenous drug users (IDU). Additional information on PrEP is available on the U.S. Centers for Disease Control and Prevention (CDC) website.
As of Feb. 9, 2018, Truvada is the only ARV approved by the U.S. Food and Drug Administration for use as PrEP.
PrEP Patient Assistance Program (PAP)
| Gilead Sciences | 877.505.6986; giledadvancingacess.com | This program covers the first $400 per month/$4,800 per year of co-payments for Truvada. Automatically renews annually for enrolled patients. |
PrEP Cost-sharing Assistance Program (CAP)
| Gilead Sciences | 877.505.6986; giledadvancingacess.com | This program is open to those up to 500% of the Federal Poverty Level (FPL). |
Post-exposure prophylaxis (PEP) involves taking antiretroviral (ARV) medicines very soon after a possible exposure to HIV to prevent becoming infected with the virus. PEP should be started as soon as possible to be effective and always within 72 hours (3 days) after a possible exposure to HIV. If your health care provider thinks PEP is right for you, you’ll take 3 or more ARV medicines every day for 28 days.
Contact your care provider or local AIDS service organization for help getting started. Clinicians can call the national PEP hotline at (888) 448-4911 for expert guidance, or go to nccc.ucsf.edu/clinician-consultation/pep-post-exposure-prophylaxis. Additional information on PEP is available at the HIV Clinical Guidelines Program and on the CDC website.
NOTE: Some of these medications are recommended for PEP only under certain conditions. The most commonly recommended regimen for PEP is Truvada plus Isentress or Tivicay.
PEP Cost-sharing Assistance Programs (CAP)
CAPs and PAPs are available for PEP, but each company has different policies for applying and delivery of medications. See detailed instructions for each pharmaceutical company below and on the following page.
|
DRUGS COVERED |
MANUFACTURER AND |
ASSISTANCE |
|
Kaletra |
AbbVie 800-222-6885; |
The cost-sharing assistance covers the first $200 per Kaletra prescription. |
|
Reyataz |
Bristol-Myers Squibb 888-281-8981; |
The program covers up to $7,500 annually for co-payments, deductibles, and co-insurance in all commercially-insured plans for Reyataz. |
|
Emtriva, Truvada |
Gilead Sciences 877-505-6986; |
Truvada: Covers the first $4,800 per year of co-payments. |
|
Prezista |
Janssen Therapeutics 800-652-6227; |
Co-payment assistance starts after the first $5 paid by the consumer, then unlimited co-payment coverage. |
|
Isentress |
Merck and Co. 800-850-3430; |
Covers the first $400 per month of co-payments. |
|
Epivir, Lexiva, and Tivicay |
ViiV Healthcare 844-588-3288; |
Covers up to $200 of co-payment on each ViiV prescription, except Tivicay. For Tivicay, the program covers the first $400 per-month |
|
DRUGS COVERED |
MANUFACTURER AND CONTACT INFORMATION |
FINANCIAL ELIGIBILITY |
ACCESS INFORMATION |
|
Kaletra |
AbbVie 800-222-6885; |
500% FPL |
1. Complete an application; indicating TRAUMA on the application (this will expedite processing). 2. Fax to: 732-584-0905. 3. Call AbbVie, noting that you sent a fax for a TRAUMA case. 4. AbbVie will send medications to provider. If received by 12:30 PM, will have overnight delivery (about 24 hours). If received after 12:30 PM, will have next day delivery (about 48 hours). |
|
Reyataz |
Bristol-Myers Squibb 888-281-8981; |
300–500% FPL |
1. Complete an application; indicating POST EXPOSURE on the application (this will expedite processing). 2. Fax to: 1-888-281-8985. 3. Call Bristol-Meyers Squibb, noting that you sent a fax for a POST EXPOSURE case. 4. Bristol-Meyers Squibb will send medications to provider or patient. Medications are shipped overnight, except on Fridays. |
|
Emtriva, Truvada, |
Gilead Sciences 877-505-6986; |
500% FPL |
1. Fax a letter of medical necessity to 1-800-226-2056, including: patient’s name, therapy needed, date of exposure, provider’s signature. 2. Call Gilead at 1-800-226-2056 and notify them you have a patient who needs PEP Monday–Friday, 9am–8pm EST.). Tell them you faxed a letter of medical necessity. Give them time of fax, number of pages, your fax number. Have the patient’s information available: name, address, phone number, date of birth, Social Security number, number of people claimed as dependents, household income, any insurance coverage, provider name, provider address, provider phone number, and parental/guardian signature of consent for any patient under 18 years of age. 3. Gilead Sciences will give you a voucher number to place on the prescription. The patient may go to the pharmacy to fill the prescription with no out-of-pocket expense. |
|
Prezista |
Janssen Therapeutics 800-652-6227; |
200% FPL |
1. Complete an application, selecting PHARMACY CARD on the application. 2. Fax to: 1-888-526-5168. 3. Call Janssen Therapeutics 1 to 2 hours after sending the fax to receive pharmacy card number. Write the number on the prescription. The patient may go to the pharmacy to fill the prescription with no out-of-pocket expense. |
|
Isentress |
Merck and Co. 800-850-3430; |
500% FPL |
1. Complete an application; indicating PRESCRIBING PEP on the application (this will expedite processing). 2. Fax to: 1-866-410-1913. |
|
Epivir, Lexiva, Tivicay |
ViiV Healthcare 844-588-3288; |
500% FPL |
Call ViiV Healthcare, indicating IMMEDIATE ACCESS. Registered Advocate (i.e., on-going medical provider or case manager) must call on patient’s behalf. First-time advocate can register at the same time of call for a patient. Application and all documentation for income and insurance must be faxed in after call and approval. Upon approval, patient can pick up medication that day from any retail pharmacy. |
Special thanks to NASTAD’s Britten Pund and Amanda Bowes. Adapted from Pharmaceutical Company Patient Assistance Programs and Cost-Sharing Assistance Programs for PrEP and PEP: bit.ly/1eFG2GU