Patient Assistance Programs and Co-payment Assistance Programs: Resources for Accessing HIV Treatment

What are these programs for and not for?

Patient assistance programs help people who do not have insurance or whose insurance does not cover a specific medication to have access to the medications they need at no or low cost.

Co-payment assistance programs help people who have insurance to lower or eliminate the amount they owe as a deductible, co- insurance, and/or co-payment for a specific medication.

Many pharmaceutical companies offer prescription assistance and co-payment assistance programs. With very few exceptions, these programs are just to get access to a medication once it has been prescribed to you by a health care provider. The cost of the health care provider’s visit to get the prescription and any lab testing necessary to get the prescription are typically not covered by the pharmaceutical company assistance program.

How do I get enrolled in and stay qualified for a program?

1. What are the eligibility requirements?

   Each pharmaceutical company (aka drug company, manufacturer) sets eligibility criteria to get enrolled in their programs. This means that they identify what will qualify you to have access to free/low-cost medication. For patient assistance programs, companies may set an income cap and for co-payment assistance programs, companies set a dollar cap.

How do I get enrolled in and stay qualified for a program?

1. What are the eligibility requirements?

   Each pharmaceutical company (aka drug company, manufacturer) sets eligibility criteria to get enrolled in their programs. This means that they identify what will qualify you to have access to free/low-cost medication. For patient assistance programs, companies may set an income cap and for co-payment assistance programs, companies set a dollar cap.

   An income cap means that your total income must be no more than a specific amount to qualify for their program. Different companies have different income caps based on a federal income criterion, the federal poverty level or FPL. Read more. Companies typically have you report your income, and they do the calculation for you. For 2023, to qualify for a program with a:

   • 300% FPL income cap, your income must be no more than $43,740
   • 400% FPL income cap, your income must be no more than $58,320
   • 500% FPL income cap, your income must be no more than $72,900
   • 600% FPL income cap, your income must be no more than $87,480

   A dollar cap means that the company has decided what the average cost for a medication per month is on most insurance plans. The company then caps the amount they will support for that medication per month, or year. The company tells you up-front how much support they will provide to access the medication per month (i.e., $100 per month) and/or per year (i.e., $1,200 per year). Once you hit the dollar cap, you are responsible for paying the remaining deductible/co-insurance/co-payment to access the medication.

2. How do I actually get enrolled?

   You must apply individually for each medication you need help getting unless the medications needed are manufactured by the same company. Each company has different eligibility requirements, but most collect the same information to complete their applications. Some require you to call and talk to someone to be enrolled, others allow an online application. It can sometimes be a little complicated, but don’t let that deter you!

   The health care provider that prescribed you the medication or your pharmacy can also assist with the process and paperwork to get enrolled and sometimes they need to complete part of the application, too. You should let your provider know that you are applying for a patient assistance or co-payment assistance program, as it can also help the process to move faster.

   For each medication, we provided a brief explanation of how to enroll in the assistance program (see “Resources for Accessing HIV Treatment” in separate PDF).

3. How do I stay in the programs?

   Once you are enrolled, you can access the program for 12 months. Most programs require you to re-enroll every year to maintain access. The purpose of this is to make sure you are still eligible for the program. Annual re-enrollment builds on the previous year, so the process should be a little simpler each year you complete it.

How do I actually get medications through these programs?

Once you enroll in the program, the company will tell you how to get the medications.

For patient assistance programs, some companies use a pharmacy network and they will send a prescription to a pharmacy near you that is a member of that network; some companies let you pick up your prescription through your choice of pharmacy, such as one in your neighborhood or the one where you get all of your other medications from; some companies mail your prescription to you; and some companies mail your prescription to your health care provider. The company will let you know specifically where you can get your medications.

For co-payment assistance programs, you will pick up your prescription through your regular pharmacy that you get all your other medications from. This is typically the pharmacy that your insurance has approved. The company will let you know specifically where you can get your medications.

What happens next?

You went to a health care provider, got a prescription, and got support to get your prescription through one of these programs. But, patient assistance programs and co-payment assistance programs do not cover your health care providers’ visit or laboratory tests. As soon as you can, you should get connected to consistent care to help to cover those costs, if you need it, and to support you in taking your medications as prescribed. Some health care providers even have programs that can help reduce or cover the whole cost of office visits and laboratory tests. Here are some places that you can find a provider near you:

• For access to HIV testing, prevention, care, and treatment services, use the HIV.gov HIV services locator learn about places near you where these services are available.
• For more comprehensive healthcare needs, Find a Health Center (hrsa.gov) near you that can connect you to a provider.
• For access to HIV and other medications, including health care provider’s visits and lab testing, connect with your state Ryan White HIV/AIDS Program Part B and AIDS Drug Assistance Program: Directory of AIDS Drug Assistance Programs | ADAP DirectoryExit Disclaimer

What about the other medications that I take? Is there a patient assistance program or co-payment assistance program for medications not on this list?

Many pharmaceutical companies (aka drug companies, manufacturers) offer help to access their medications. Here are some ways you can find out if there is assistance available to access your other medications:

• Talk to the health care provider that prescribed you the medication.
• Do a search online for “your medication” and “patient assistance.” The results should take you to a page for the medication you take and the options that are available.
• Look up the manufacturer of your medication to see what programs they offer on their website.