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. State AIDS Drug Assistance Programs (ADAPs), several non-profit organizations, and the pharmaceutical companies themselves have programs in place to help you pay for the treatment you need.
A cost-sharing assistance program (CAP, also known as a co-pay program) 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. Unfortunately, many big health insurers have now introduced co-pay accumulators to their plans, and 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. When choosing your healthcare plan, make sure your drug is covered (on the plan formulary) and know which drug tier it is in (your cost for the drug co-pay is based on which tier, or category, it falls under).
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 combines common information collected on each individual company’s form to allow individuals to fill out just one. 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.
In addition to serving as a special PAP for ADAP waiting list clients, 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.
Information in this article and the tables on the following pages are adapted from NASTAD’s “HIV Pharmaceutical Company HIV Patient Assistance Programs and Cost-Sharing Assistance Programs”: nastad.org/resource/pharmaceutical-company-hiv-patient-assistance-programs-and-cost-sharing-assistance-programs.
* 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).
Providing access to care assistance for people living with HIV
Harbor Path
Provides access to free medications for uninsured people living with chronic illnesses; administers AIDS Drug Assistance Program (ADAP) Waiting List Program.
PAN Foundation
(866) 316-7263
Provides necessary healthcare treatments to the underinsured population.
Patient Advocate Foundation
(800) 532-5274
Provides arbitration, mediation, and negotiation services to settle issues with access to care, medical debt, and job retention related to illness.
Additional resources
These may be of interest to individuals living with HIV
Clinical Trials
A service of the U.S. National Institutes of Health, ClinicalTrials.gov is a registry and results database of publicly and privately supported clinical studies of human participants conducted around the world.
Fair Pricing Coalition (FPC)
As part of their advocacy work, the Fair Pricing Coalition (FPC) negotiates with companies to ensure that cost-sharing and patient assistance programs are adequately generous and easy to apply for.
Health Insurance Marketplace
The official site of the Health Insurance Marketplace, Healthcare.gov allows individuals and families to sign up for insurance coverage through the Affordable Care Act.
Treatment Action Group
Treatment Action Group collaborates with activists, community members, scientists, governments, and drug companies to ensure that all people with HIV, TB, or HCV receive lifesaving treatment, care, and information.