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Patient Assistance Programs (PAPs are programs created by pharmaceutical and medical supply manufacturers to help financially needy patients purchase necessary medications and supplies. Via these programs, prescription medications may be made available at no cost or at a minimal fee for individuals who do not have insurance or are underinsured.
There are several types of PAPs. There are ones that are designed for patients that do not have insurance, others for individuals whose insurance co-payment amounts are prohibitively expensive, and still other programs to assist with specific types of insurance, such as Medicare Part D.
Why do pharmaceutical companies have PAPs? There is not a black and white answer to this question. Pharmaceutical company representatives will respond by discussing their organizations’ commitments to social health. Social medicine advocates may argue that these companies are doing the minimum possible and that they make participation in their programs difficult by adding layers of bureaucratic red tape. The true answer may lie somewhere in the middle. It makes good business sense to have a PAP. Patients who otherwise could not afford their medicine receive it, the pharmaceutical company receives partial payment from the insurance providers, and they get the positive PR from the program.
The eligibility requirements differ for each organization’s patient assistance program. What follows are the typical requirements for this type of program.
Participants in patient assistance programs are required to provide proof of the need for a prescription or medical supply. Typically a written prescription for a medication is adequate but in some cases separate documentation from the applicant’s doctor is required.
Typically eligibility is based on one’s income, with the income limit being set by each individual pharmaceutical company. Many PAPs opt to use the Federal Poverty Guidelines, or some percentage thereof, as income thresholds. For example, if a company sets one’s income limit to equal or less than 300% of the Federal Poverty Guideline (approximately $36,180 in 2017 for a single individual), then they would likely qualify for assistance.
Other companies set their income limits in real dollar amounts, which vary greatly among the companies. Most programs have income maximums of between $30,000 - $48,000 for individuals, and for couples between $40,000 - $64,000.
Some assistance programs have two-tiered eligibility requirements. For example, if your annual income is below $20,000 / year, the prescription or supplies might be completely free, or if your income is under $30,000, you might receive a 75% price reduction.
It is important to note, income itself may not be the sole factor in determining financial eligibility. A patient’s out-of-pocket cost for a medication has an impact as well. Some medications, even with insurance, require patient co-payments of $100s or even $1,000s per month. In these instances, eligibility decisions may be made by the gap between a participant’s income and their costs instead of based solely on their income.
Some patient assistance programs require an individual to have insurance; others are only available to those without insurance. Therefore while insurance can be an eligibility factor, it is specific to the program. Note that some pharmaceutical companies may have different assistance programs entirely for persons who have and do not have insurance.
The candidates marital or veteran's discharge status does not impact their eligibility. For most programs, age is also not a factor. One's geographic location only matters insofar as they must reside within the United States or at least have a shipping address within the U.S.
Each patient assistance program has a different structure. Typically they provide assistance in one of the following four ways:
1) Reimbursement – your costs or a percentage of your costs are reimbursed after purchasing and providing receipt.
2) Coupons – discount coupons that you redeem directly with your pharmacy or supplies company.
3) Direct discounts at your pharmacy – the program has a direct relationship with the pharmacy and the discount is applied at purchase.
4) Free product – shipped directly to the program participant.
Benefit amounts depend both on the patient assistance program and the participating individual’s needs and resources. Some participants may receive as much as a 100% discount on their supplies and medications, while other may only receive a 20% discount.
Each patient assistance program also has its own timeline. Processing and delivery of benefits can happen in as little as one week’s time or can take several months.
The duration of one’s enrollment in a patient assistance program varies. Some programs require participants to reapply with each new prescription, while others require annual re-application. Most programs will provide a 90-day supply.
Since these programs are designed for the financially needy, typically there is no cost to participate in the program. In the rare case where there is a fee, the net savings will more than cover the cost of the fee.
There are also third party services that will manage the application and renewal process on their clients’ behalf. These services may charge their clients on a per-medication basis, per-program basis, or an annual flat fee. While it is not difficult for most adults to manage the application and renewal process, some elderly patients may find the process frustrating or confusing. For these individuals, these services may be worth the small fees they charge.
One applies for a patient assistance program directly with the pharmaceutical company or supply manufacturer. Typically they will request the applicant’s age, state of residence, income, prescriptions, insurance and medical providers information. Be aware that some programs require you to re-apply with each new prescription.
The easiest way to determine if there is a patient assistance program available is to make a list of medications and search this online database of patient assistance programs and then use the contact information provided.
As mentioned previously, there are also third party services that will manage the application and renewal process on their clients’ behalf. Typically these services charge their clients on a per-medication or per-program basis each month.
For persons who know the manufacturer of their medication, below are direct links to the largest pharmaceutical companies' patient assistance programs. Alternatively, one can search for assistance by the name of the medication or search for the generic equivalent.