Meeting Rx Costs: Help From an Unlikely Source

by Eve B. Scheffenacker

The cost of prescription drugs is a hot topic in the news and in personal conversations. Many of us know someone whose budget is stretched to its limit by the monthly prescription bill. In fact, seniors and people who are uninsured or underinsured may have to go without something to afford their medication, or go without medication. That could be the same as getting no health care, because many of the newer drugs replace or reduce the need for more expensive medical treatments.

That's the dilemma Harriet Taylor faced. An independent business owner in Baltimore, Taylor has individual health insurance that doesn't cover any treatment of mental health conditions, including medication. She also had a struggling business. "My annual income was barely $15,000. I was living off my savings, and they were going fast," Taylor relates. "I denied the fact that I was seriously depressed because I couldn't afford the medication. But I reached the point where I knew my business would fail if I didn't get the drugs." The medication would take more than $275 a month out of her shrinking savings. Harriet checked some Canadian mail order services; they didn't carry her medications. She also learned that neither of her drugs was available in generic form. She was about to ask her family to lend her the money when she found a provider who solved her problem: prescription drug patient assistance programs.

Most drug companies provide brand drugs to qualifying low-income and uninsured patients at no cost.

Almost all pharmaceutical companies have these programs, known in the industry as "indigent patient assistance" programs. Through them, the companies provide their brand drugs to uninsured and low-income patients at little or no cost. (The definition of low-income will vary.)

Getting assistance

Although these programs are industry-wide, they all work differently:

Almost all companies require paper applications; a few accept telephone registrations. In addition, some companies will preregister patients by phone and give temporary coverage to those who appear to qualify.
All the programs use family income, size of household, and available insurance coverage as eligibility standards. Their income limits usually are tied to the annual poverty guidelines, setting the cap anywhere from 150% to 200% of the poverty guidelines. Many companies require pages of documentation, including copies of tax returns, to support claims made in the applications. However, some ask a simple yes-or-no question about your income and trust you to be honest. In some cases, programs also consider your out-of-pocket expenses for other medical care.
Every patient assistance program works differently.
Some programs will qualify you for up to a year; others give six-month approval, and still others review you every three months.
Merck, Eli Lily, and GlaxoSmithKline are among the many companies that make all or most of their drugs available through their programs. Others offer a few select brands. Also, a number of companies have separate programs for certain categories of drugs, such as cancer or HIV/AIDS medications.
Members of many programs can pick up their prescriptions at their pharmacies, using a membership card. In other cases, the company ships the drugs to the provider or the patient.

Perhaps the only common factor among these programs is the fact that your prescriber has to submit the application for you. He or she also will be the main contact for renewing your eligibility, as well as the intermediary for any exchange between you and the program.

A well-kept secret?

How much do doctors and other prescribers know about these programs? The answer varies from practice to practice and doctor to doctor. Most doctors know these programs exist. However, the myriad program differences and the role they'd have to assume keep many doctors from using the programs except for the most obviously needy patients. Learning the various ropes would be almost like learning a new medical subspecialty. And keeping track of patients' status in dozens of programs would mean they'd spend even more time with paper instead of people. Hospitals, which have the systems to manage the process and a large volume of low-income patients, are among the largest program users of these programs. So are providers such as cardiologists or psychiatrists who often prescribe costly maintenance medication for chronic conditions.

Family income and available insurance coverage determine your eligibility.

Doctors often don't know the cost of the medications they prescribe, nor are they likely to know the details of every patient's finances. And patients may hesitate to offer that information. But if you, a friend, or family member is struggling to pay prescription costs, speak up. Find out what the doctor knows about the relevant programs and do some research to improve his or her knowledge. You can find a lot of information about corporate patient assistance programs online. Several organizations, such as RxAssist, have complete lists of companies, the drugs available through their programs, and contact information. (These sites also may have information about state programs, some of which are open to nonresidents.) If you qualify for any or all of the programs, the financial and emotional relief will improve your health overnight.

Most doctors know about these programs; fewer use them regularly.

Pharmaceutical altruism?

The pharmaceutical companies aren't running assistance programs for the sheer joy of giving. This effort is part of a negotiated agreement between the drug industry and Congress. The drug companies agreed to provide medication for uninsured and low-income patients. In return, Congress agreed not to legislate cost controls for brand drugs--an act that would have benefited all patients. The beneficiaries of these programs can't even take pleasure in putting an infinitesimal dent in the industry's profit margin. In addition to freedom from cost controls, the companies get a generous tax credit for the "charitable contributions" they make to needy patients.

Useful resources

Published February 23, 2004

Printed Wednesday, November 25, 2009

Progressions Credit Union