Prescription Assistance Programs CLAIM Missouri State Health Insurance Assistance Program Duane Thran Volunteer Counselor Stacey Childs Regional Liaison/Trainer

Prescription Assistance Programs “Finding non-governmental assistance programs for a Medicare beneficiary’s higher cost drugs can result in MEGA SAVINGS for the beneficiary, which may be much more beneficial than finding the lowest cost Medicare drug plan.” Anonymous

First Step Always screen the beneficiary for Extra Help or Low Income Subsidy (LIS) with SSA Benefits are lower premiums, deductibles and copays Income limit is lower than prescription assistance programs Beneficiaries with Extra Help may still be eligible for prescription assistance programs

Recommended Tools Needymeds.org Rxassist.org Planfinder in Medicare.gov

Lower Your Drug Costs - PlanFinder

Lower Your Drug Costs - PlanFinder

Lower Your Drug Costs - PlanFinder

Types of Assistance Programs Patient (Manufacturer) Assistance Programs (PAPs) Foundation (Charity) Assistance Programs

Patient Assistance Programs (PAPs) Many higher cost brand name drugs have PAPs from the manufacturer Some PAPs exclude Medicare beneficiaries Some PAPs consider Medicare beneficiaries on a case by case basis If eligible, medications are normally provided at no cost

Eligibility Requirements for PAPs Income limits – 200%-500% of FPL 200% single $2023/mo couple $2743/mo 500% single $5058/mo couple $6858/mo No asset/resource limit For some PAPs, beneficiary can’t be eligible for LIS For some PAPs, CY OOP costs on meds have to exceed 3%-5% of annual household income For some PAPs, CY OOP costs on meds must exceed a fixed dollar amount 200% single $2023/month couple $2743/month 300% single $3035 couple $4115 400% single $4046 couple $5486 500% single $5058 couple $6858

Other Factors for PAPs Applications by paper, online or phone Prescriber usually needs to complete a section of the application Not all forms of the medication may be available in a program Delivery of Rx may be direct to patient, to prescriber or to pharmacy

Documentation Needed for PAPs Tax returns or 1099s to support income EOB from pdp or MA to support ytd OOP costs for meds, if required Denial letter from LIS application, if required

PAPs for Common Rx Insulin and diabetes medications Inhalers Other common medications

Insulin/Diabetes Assistance

Inhaler Assistance

Other Rx Assistance

Other Rx Assistance

Types of Assistance Programs Patient (Manufacturer) Assistance Programs (PAPs) Foundation (Charity) Assistance Programs

Foundation Assistance Programs Individual funds for specific diseases Dependent on funding Each fund may close, reopen or limit it to renewals at any time Most income limits are 400%-500% of FPL 400% single $4046/mo couple $5486/mo 500% single $5058/mo couple $6858/mo

Foundation Assistance Programs No asset/resource limits Most operate with fixed amount of a grant Some funds also give assistance for premiums or medical costs Most program websites reference other funds/resources

Common Foundation Programs Patient Assistance Network (panfoundation.org) Healthwell (healthwellfoundation.org) My Good Days (mygooddays.org) The Assistance Fund (tafcares.org) Leukemia & Lymphoma Society (lls.org) Cancer Cares (cancercare.org) Patient Advocate (copays.org) Patient Services Inc (patientservicesinc.org)

PAN Foundation Income limits are 400% and 500% of FPL Diagnosis for disease/condition for fund Must have insurance that covers qualifying medication Can apply online or over the phone Grants for 12 months and 90 days prior to approval

PAN Foundation Assistance is renewable if funds available Patient are given PAN ID card where pharmacy submits claims to PAN Patient can be notified when a closed fund is open again Some current open funds Heart failure $800 Multiple Myeloma $8400 Definition of heart failure is that heart can’t pump enough blood to meet the body’s needs. Common causes are coronary artery disease, high blood pressure and diabetes.

Healthwell Foundation Income limits are 400% and 500% of FPL Diagnosis for disease/condition for fund Must have insurance that covers qualifying medication Assistance through grants and using pharmacy card Can not be used with other foundation assistance programs

Healthwell Foundation Some current open funds Gout $12000 (copay/premium) Melanoma $25000 (copay/premium) Multiple myeloma $10000 (copay/premium) Post menopausal osteoporosis $1000 (copay/premium) Secondary hyperparathyroidism $4000 (copay/premium) Cancer related behavioral health $2000 (copay/medical)

Cancer Cares Income limit of 500% of FPL Grants begin at $4000, Maximum of $10000 Some types of cancer with current open funds Melanoma Cervical Pancreatic

Other Counseling Tips for Rx Costs Generics/Samples/Alternative Rx Formulary and tier exceptions Preferred network pharmacies 90 day supply/mail order Rx Outreach/Good Rx Other discount programs Missouri Rx

SHIPTALK Entry

Final Takeaway “Finding non-governmental assistance programs for a Medicare beneficiary’s higher cost drugs can result in MEGA SAVINGS for the beneficiary, which may be much more beneficial than finding the lowest cost Medicare drug plan.” Anonymous

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