PhRMA stands for Pharmaceutical Research and Manufacturers of America. Those manufacturers run a Partnership for Prescription Assistance (PPA) service. That is what the PPA in PPARX.org represents, RX is shorthand for prescription.
The service creates and easy way for patients to find Patient Assistance Programs (PAPs).
#1 Who needs PAP’s like PPARX?
A study done by Kaiser foundation in 2015 found that just over 1 million Medicare part D enrollees reached the catastrophic coverage level which was more than double the number in 2007.
Catastrophic coverage means they have exceeded the amount due in the coverage gap where you are responsible for the full cost of medications. For 2018 once you have spent $5,000 out of pocket, you are in the catastrophic range and you will only pay a small coinsurance or copayment for covered drugs the rest of the year.
Most commercial insurance plans are set up in a similar fashion. This increasing trend of very high spending is expected to continue.
#2 What is the patient assistance program?
Patient assistance programs (PAP’s) are programs created by pharmacuetical manufacturers to help financially needy patients obtain necessary medications. The manfuacturers set these up as nonprofit charitable organizations. Through these programs, medications are available at no cost or at a minimal fee.
Many types of PAPs exist, including those for patients that do not have insurance, for individuals whose whose insurance copayment amounts are very expensive, and other programs to assist with specific types of insurance. The programs target patients with low and moderate incomes and older adults and those suffering with chronic conditions that require multiple medications and thus face the greatest need for these types of services.
PAP’s are funded through donations and thus do not continually have funding to keep the program open. Patients need to confirm if funding is still available before enrolling in the programs.
#3 Why try PAP’s first?
Specialty medications are increasing rapidly as a percentage of all spending on medications. However, specialty brand and generic drugs can all have PAP programs of one type or another. More patients are exposed to higher cost sharing with complex drug therapies thanks to high deductible health plans. This leads to a need for more assistance. Many manufacturers offer coupons and discounts, but that is NOT the first place to look for assistance.
Most people do not realize you should always look for patients assistance programs first. They are different with some set up as charitable non-profit organizations. PAP’s may be owned by one manufacturer, while others have multiple drug companies that come together to form a PAP. Many times theses will be associated with a disease state.
#4 Why did PhRMA create PPARX?
PhRMA companies want you to utilize their drugs. They provide programs to help underserved patients be able to afford medications. Since these foundations are set up as non profits, the donations can be written off. That means each PhRMA member company can write off large profits with charitable donations of mediation, while still helping people.
Partnership for Prescription Assistance (PPA) claims to have helped more than 10 million patients get access to patient assistance programs. PPARX provides access to over 475 patient assistance programs. These programs are available for more than 2,500 prescription medicines, both brand and generics.
#5 Tool for searching PPARX
In an effort to increase transparency of pricing PhRMA companies developed the Medicine Assistance tool. This tool provides patients with information to help make decision about their medications. The Medicine Assistance Tool (MAT) is a search engine that allows you to quickly find information about various resources available from pharmaceutical manufacturer programs.
There are three steps to finding information on medication using MAT.
- Enter the medication name, brand or generic.
- Provide your information to see if there are resources based on:
- Number of people in household
- Total yearly household income
- Residency status
- Insurance status
- Recent natural disaster
3. Review the results thoroughly to determine the best course of action.
#6 How to search other PAP’s
The most efficient way to search for PAP programs is to go to Needymeds.org. This is the most complete collection of information on PAP programs out there today. Needymeds itself is a non-profit organization funded by donations, but not PhRMA. Searching is easy by going to the patient assistance tab. There you can search by drug name via brand or generic. You can also easily search by disease state.
Needymeds shows other ways to save on medications including discount cards, copay coupon cards and PAPs. The PAP programs have a specific icon and clicking on that icon lets you know the eligibility requirements for that program.
#7 How to qualify
While enrolling in PAP’s can be time consuming, it can be well worth it considering the amount of savings that could be realized. A few simple tricks will help you quickly decide it you should apply for a PAP program.
All PAP’s are setup for those in need and guidelines can vary from program to program. There are no laws governing PAP’s, so you simply need to meet eligibility requirements. A few examples include:
- Medicare vs commercial insurance
- Household size
The first component will be income level as a percentage of the federal poverty level (FPL). Don’t despair; these limits are not just for people below the FPL! Some allow for up to 500% of the FPL, which is a good amount of income.
Eligibility may also be based on insurance status and family size. Needymeds has a calculator on their site that will calculate where you fall as a percentage of FPL. Simply put in your income as reported on your tax documents and the previous year and the number of people in your household.
Then whala, the calculator spits our where you fall as a percentage of FPL.
#8 What if I am above the FPL?
If your FPL number comes in just above the FPL of the PAP in question, do not write the program off. Instead contact the PAP and ask them to make an economic hardship request. These requests are often granted and definitely worth the time. Each PAP will have a number you can contact to make the request.
#9 What about insurance?
PAP assistance will be denied to most people who are on Medicare and eligible for drug benefits from any public assistance program including state and local programs. Medicare beneficiaries who don’t have drug coverage will be able to get assistance on a case by case basis. Any assistance received from a PAP for a Medicare patient would not count toward you out of pocket expenses.
This means the assistance amounts do not apply toward:
- Initial coverage limit
- Catastrophic coverage limit
Most Medicare and Medicaid patients would need to apply for other types of public assistance before they could qualify for a PAP. The part D low income subsidy would be an example. More information can be found at www.cms.gov.
Keep in mind that CMS tracks who gets PAP funds. They have instituted data exchanges with PAP programs, including State PAP’s to help them coordinate the Medicare Part D drug benefit. The data exchange allows them to accurately pay claims through the program and calculate the true out of pocket expenses mentioned above. Therefore, you should not try to avoid accurately reporting PAP monies on taxes or other legal documents.
#10 Can I get a prescription without seeing a doctor?
All PAP programs will require a valid prescription from a doctor. 7 essential steps to prepare for a doctors appointment checklist can get you ready for the conversation.
Once you find the program on Needymeds.org site you can click on the link of the actual website for the PAP program itself. The applications can be filled out on the internet in most cases or printed off.
Your doctor must complete part of the application for you to be eligible for assistance. It is highly recommended that YOU do the research on the various program ahead of speaking to your doctors office about doing the paperwork. Knowing the programs you may qualify for will save everyone time and money if the office charges you to complete paperwork. Due the increased number of these requests doctors receive many do charge patients out of pocket for this service.
Remember your doctor is not the best resource for information on PAPs. In fact, they may not even know what they are. Pharmacists are likely to be more aware, but still not up to date on all the programs available.
#12 Simplify the process
Once you print off and complete your part of the application contacting the doctors office is the next step. Some applications only require a doctors signature, but some may require them to complete a large medical section. Call the office and see if they handle these on a walk in basis and or if it may take them a day or more to complete. Below are the best practices for you.
- Print and complete all patient sections as best as you can.
- Complete doctor demographics for them (name, address, phone number).
- Don’t be surprised if the doctor doesn’t fill out the form right away or has staff work on it.
- If the doctor must fax the information, make sure you have income documentation ready for them.
Doctors are busy and they will greatly appreciate you taking the time to complete as much of the application as you could. They may even be more likely to try and help you. If they do charge a fee to complete the paperwork, it makes sense to pay it. Especially since you already confirmed you qualify for the assistance. The fee will be much less than the potential savings you could realize.
#13 My doctor will not complete PAP paperwork?
In some cases doctors become fed up with PAP paperwork and make the decision to stop doing it altogether. What can you do if this happens to you?
- Tell the doctor for you to be able to take the medication, it must be affordable.
- Ask if there are other less expensive medications?
- If all else fails, look for a different doctor who will work with you.
PAP applications can seem overwhelming especially when dealing with the disease you are being treated for. Needymeds also lists PAP application assistance programs that can be searched by zip code.
Different organizations around you may be willing to help you with the paperwork and in some cases even contacting the doctor on filling out their part. You provide these companies with your health information consent and they handle the rest.
#15 What to expect
After filling out paperwork, it can take up to 4-6 weeks to hear if you qualify. These programs support millions of patients and literally give away billions of dollars in annual assistance. Don’t be in a hurry, take your time and fill out the forms completely. Ask your doctor for samples of these medications to get you through this waiting period.
PAPs will distribute the medications in a variety of ways. Many will send the medication to the doctors office and some to the pharmacy of your choice. Another method is to send you a certificate or card that can be used to fill the prescription at the pharmacy. Most PAP programs will cover your refills as well when the treatment must be used for an ongoing period.
The bottom line
Uninsured or underinsured patients tend to take less of their medication than has been prescribed due to cost concerns. Uninsured patients are twice as likely as insured patients to underuse medications due to costs, according to the Center for Medicare and Medicaid Services.
Despite more Americans having insurance, we know many face issues with access to their medicines, putting their ability to stay on a needed therapy at risk. Patient assistance programs sponsored by pharmaceutical companies are a solution to helping patients maintain access to needed medicines if they are uninsured or underinsured.
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