Prescription Drug Patient Assistance Programs
A patient assistance program (PAP) is a financial assistance program that aids in the cost of prescription drugs. Some of these programs are run by charities, while many are run by pharmaceutical companies themselves. There are also state-run programs to lower drug costs in several, but not all, states that supplement Medicare or Medicaid coverage or provide other help to people not enrolled in those programs. To get the benefits of such programs, patients usually must apply for assistance.
PharmacyChecker’s main goal is to help you afford prescription drugs. To do so, we identify the safest international online pharmacies and compare their drug prices with local pharmacy prices in the U.S. Our U.S. Prescription Discount Card also helps patients save a lot of money at local U.S. pharmacies. These solutions may provide all the prescription assistance you need, but not always. Also, while it is a common practice among millions of Americans seeking lower drug costs, medicine imports for personal use are technically prohibited under most circumstances. There are patient assistance programs out there that can potentially help you try to obtain your medicine within the U.S. first.
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Below, you will find a comprehensive summary of these programs with links to the governmental and organizational websites to help you do more research. The programs discussed here are for those living in the United States.
Patient Assistance Programs
If you cannot afford an expensive medication, some pharmaceutical companies and nonprofits have patient assistance programs to help consumers get financial relief. Some programs help you get your medication completely free, covering the entire cost, while others cover a portion of costs or just help with a small discount.
These programs, whether provided by pharmaceutical companies or non-profit organizations, do not accept everyone. They often have strict eligibility requirements having to do with your income and the type of insurance you have. [GL1] Enrollment requirements vary from program to program, but you can expect to have to meet the following criteria:
- You must be a resident of the United States
- Patients must prove they are uninsured or that their insurance doesn’t cover prescribed medications
- You must meet income eligibility requirements
What are the income eligibility requirements to receive patient assistance?
Many patient assistance programs use Federal Poverty Guidelines to determine eligibility. For example, a pharmaceutical company could set their income limit to less than 400% of the Federal Poverty Level (FPL). Since the FPL was approximately $12,040 in 2019 for a single individual, 400% of FPL is about $48,160.
Some companies set income limits in dollar amounts, which vary from program to program. We’ve seen programs that have income maximums of $23,500 - $50,000 for individuals, $17,701 and $67,640 for couples.
If you think you may qualify for a PAP, we suggest that you visit the website of NeedyMeds, a non-profit organization that has detailed and up-to-date information on the programs.
Read our Ask PharmacyChecker post: Whom do patient assistance programs really help?
Federal Government Programs
The largest federal programs that help enrollees afford prescription drugs are Medicaid, Medicare, and the Veterans Health Administration.
Medicaid, which is mostly dedicated to helping Americans with low incomes, is the largest government health insurance program in the U.S. It’s funded by the federal government and individual states. The program generally provides substantial prescription drug coverage, but affordability problems are still common.
Medicaid’s minimum standards are established at the federal level, but states have wide latitude in determining eligibility and benefits. The Affordable Care Act ensured eligibility to people with incomes at or below 138% of the Federal Poverty Level, but that provision was struck down by the courts.
All states still have eligibility rules based on your income’s percent of the FPL. In some states, if your income is below a certain level, then you will definitely qualify for Medicaid. In addition to a person’s income, people can also qualify, depending on the state, if they are pregnant, disabled, 65 or older, or based on family size.
In Medicaid, prescription drug coverage is determined by states. While not required under federal law, all states offer some prescription drug coverage in Medicaid. Copayments are very low for Medicaid enrollees at or below 150% of the FPL. That goes for preferred drugs, generics and brands. Even non-preferred drug copays are low. In Pennsylvania, for example, the copay for generics and brands is $1 and $3, respectively. In Montana, preferred brands are $4 and non-preferred brands are $8. Mississippi charges a copayment of $3. Many states do not charge a copayment for generics at all and other states, including Rhode Island and Texas, do not have copayments for generics or brands.
Unfortunately, if your income is higher than 150% of the FPL, then the prescription drug costs can be substantial: 20% of a drug’s cost for non-preferred drugs. Again, it depends on the state in which you live.
If you are eligible for Medicare and Medicaid, then your prescription drug benefits will be covered by Medicare. See below to learn about Medicare prescription drug benefits.
For a great resource on Medicaid info by state see:
Kaiser Family Foundation data on Medicaid prescription drug costs by state
Read our Ask PharmacyChecker post: What are the requirements to receive Medicaid?
Medicare, which offers federally-funded health insurance to all Americans 65 and older and others with certain disabilities, also helps cover prescription drug costs. What’s often referred to as “traditional Medicare,” Medicare Part A and B help cover the costs of hospital visits and visits to your health care providers, such as doctors, nurses and other medical professionals, respectively.
Through Medicare Part D, established in 2003 by Congress, Medicare enrollees can choose a prescription drug plan (PDP). Part D is optional, but you pay a penalty premium if and when you choose a Part D plan at a later date than when first eligible to do so, or after you no longer have a pharmacy benefit plan through another source, one that was equal to or better than Part D. That penalty increases every year you forget to sign up for Part D.
Out of the 60 million people covered by Medicare, 45 million are enrolled in a Part D plan.
Part D plans are sponsored by private health insurers and pharmacy benefit managers, such as United Healthcare and CVS Caremark. Drug costs are shared among plan sponsors, the federal government, drug manufacturers, and enrollees. Another option, Part C of Medicare, called Medicare Advantage Plans, provides comprehensive health insurance and prescription drug benefits in one insurance product.
There is a total of 948 Part D plans from which to choose, an average of 28 plan options per state for the year 2020. Twenty such plans are available nationally: their average premiums range from $13 to $83 a month. The highest premium is $191.40.
The standard deductible – the highest permitted by Medicare – is $435. Some plans have zero deductibles but that usually means higher premiums.
If you have a lower income, that often means lower costs through Medicare Part D. It also means fewer plan choices. You can access what is referred to as “Extra Help” if your income is around 150% of the Federal Poverty Level. In 2019, that’s an income of $18,735 and assets lower than $14,390 if your single; an income of $25,365 and assets lower than $28,720 if filing jointly. If you’re eligible, then you should apply for extra help.
A higher income means that you pay higher Medicare Part D premiums. If your modified adjusted gross income is $85,000 or less – or, filing your taxes as a married couple, $170,000 or less – then you will not pay additional premiums. If your income is higher than those amounts, then you will.
There are four coverage phases in Medicare Part D: the deductible, which you pay until benefits kick in; the initial coverage, after your deductible, you pay 25% and the plan pays 75% of drug costs up to $4,020; above which you still pay 25% in what used to be called the coverage gap or “donut hole,” which closed in 2020 because now drug companies cover 70% and the plans 5% up to $6,350; above which you hit the catastrophic phase, in which Medicare picks up 80%, the plans 15% and you 5% of the costs.
Prescription drug coverage is adequate for many people enrolled in Medicare, but many Medicare enrollees face very high costs. Where you cannot afford a medicine while in Medicare, PharmacyChecker-accredited international online pharmacies may help, mostly with brand-name, maintenance medicines.
The best online tool to pick a Medicare drug plan is using the government’s site: https://www.medicare.gov/plan-compare/
Read our Ask PharmacyChecker post: Can I use drug discount coupons if I have Medicare Part D?
340B Program and You
The 340B Program is a federal program through which pharmaceutical companies, ones who contract with Medicaid, are required to sell prescription drugs at a discount to eligible hospitals and clinics that serve people who are likely unable to afford needed medications. It’s named after Section 340B of the Public Service Health Act, which created the program.
If you are uninsured, underinsured, or otherwise vulnerable to high drug prices, you could find relief at a clinic that offers 340B discount drug prices.
To search for a medical facility that may qualify, use NeedyMeds.org
State Pharmaceutical Assistance Programs
There are State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs (ADAPs) and other state-sponsored prescription savings programs. About 40% of states offer their own SPAPs and/or ADAPs. Some state programs are based on grants from the federal government, such as ADAPs. According to Medicare’s website, 21 states offer SPAPs and ADAPs. To help you find a program in your state, search the Medicare website here: https://www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx
Some states have several programs and others just one. For example, New Jersey has three programs. One is open to anyone 65 or older or any adult receiving Title II Social Security benefits. Colorado has one program, called Colorado Bridging the Gap, which helps people with HIV/AIDS who are enrolled in the Colorado AIDS Drug Assistance Program.
Do you have a question about other prescription drug assistance and programs? Ask PharmacyChecker and we’ll try and get you an answer.
Updated February 2020