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

2. 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

3. 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

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

5. Lower Your Drug Costs - PlanFinder

6. Lower Your Drug Costs - PlanFinder

7. Lower Your Drug Costs - PlanFinder

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

9. 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

10. 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

11. 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

12. 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

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

14. Insulin/Diabetes Assistance

15. Inhaler Assistance

16. Other Rx Assistance

17. Other Rx Assistance

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

19. 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

20. 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

21. 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)

22. 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

23. 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.

24. 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

25. 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)

26. 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

27. 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

28. SHIPTALK Entry

29. 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

30. Questions? Share Your Experiences!!
Thank You!
Questions? Share Your Experiences!!