In some cases, insurers have excluded first-line antiretrovirals from their formularies, while others required patients to pay a percentage of the drug’s cost rather than the standard flat fee. As a result, therapies that are meant to be accessible and affordable are hitting some patients hard in the pocketbook.
Co-Pay and Patient Assistance Program (PAP) Eligibility
In the effort to ensure affordable access, the FDC has negotiated co-pay and patient assistance programs (PAPs) with most every HIV drug manufacturers. Both programs provide assistance to patients who meet eligibility criteria based on the annually updated Federal Poverty Level (or FPL). The criteria for inclusion varies by program, with some PAPs, for example, providing access to those with incomes twice the FPL while allowing membership at 950% of the FPL. Additionally, the FPL is adjusted by family or household size. The FPL Guidelines are available for the 2020 calendar year.
While co-pay programs assist with the insurance co-payment of each individual drug, PAPs work to provide qualified low-cost to free medications. In most cases, verification of income is required, usually in the form of a federal income tax return.
A more recent development has been the establishment of the Common PAP Application, an initiative coordinated through the U.S. Department of Health and Human Services to streamline the application process. (Please note, however, that while the application helps reduce the amount of paperwork associated with registration, the form does still need be sent to each drug manufacturer individually.)
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