Table of Contents
- Health Insurance in the United States
- Changes Due to the Affordable Care Act (ACA)
- AIDS Drugs Assistance Program
- Health Insurance Marketplaces
- Drug Company Programs
- Clinical Trials
- Buyers' Club
- Seeking Help
Health insurance covers some of the cost of prescription drugs, including HIV drugs. The best way to get health insurance is to work for an employer who provides it. Some employers, especially small businesses, do not offer health insurance. If you do not work, or your employer does not offer health coverage, check to see if you qualify for any public health insurance programs (see below). If you do not, you may be able to buy an individual insurance plan directly from an insurance carrier.
Most insurance plans include some drug coverage. However, co-pays add up. Some people choose to get their medicines from mail-order pharmacies. Mail-order pharmacies can have benefits like lower co-pays and home delivery of medications. However, it is important to realize that mail-order pharmacies – like local pharmacies – can make mistakes. When they do, it can take some time for the correction to be made. For example, sometimes a mail-order pharmacy may send one part of your HIV drug regimen and forget to send the other part. By the time the mail-order pharmacy sends the missing drug, you may have run out of your complete regimen. Also, if you just received a three-month supply of one HIV drug in the mail and you need to change HIV drugs, you may have difficulty getting insurance to cover the new drug until you have used up the old one.
You may want to speak to your insurance carrier and your health care provider about using a mail-order pharmacy to see if it is a good option for you.
The Affordable Care Act (ACA) was signed into law by President Obama in 2010. The ACA provides for several changes that can dramatically improve the health of people living with HIV (HIV+) by increasing their access to health care. For example, it stops insurers from denying coverage to those with pre-existing conditions (like HIV or pregnancy) and stops insurers from putting lifetime or annual spending limits on insurance benefits, which often affect those living with long-term conditions like HIV.
The ACA creates health insurance marketplaces for people to buy affordable health insurance if they do not have access to employer-based programs. It also provides for changes to many programs that already help HIV+ people get their HIV drugs, like Medicaid and Medicare. For more information, read about each of the specific programs below and see The Well Project's article, The Affordable Care Act and Women in the US.
The AIDS Drug Assistance Program (ADAP) is funded by the federal government to help pay for HIV drugs for people who might not be able to afford them otherwise. Your local ADAP office can let you know which drugs it pays for and what the income limits are for your state.
Some states have a waiting list for ADAP. In other states, the ADAP program is big enough to cover not only HIV drugs, but also some medical care and non-HIV medications, such as those used to manage side effects.
Medicaid is a government-sponsored insurance program that covers healthcare and medications. If you are disabled, not working, or earning little money, you may qualify for Medicaid. Like ADAP, each state has its own program so you will need to talk to a local Medicaid worker in order to apply. The ACA will enable states to provide access to Medicaid for people living below 138 percent of the federal poverty level. It is important to note that only some states have chosen to expand their Medicaid coverage and change their eligibility requirements through the ACA; others are still deciding. Many of the states that have decided not to expand Medicaid are also the states where the highest numbers of people living with HIV live.
In addition, Medicaid eligibility will now be determined based on income alone; disability status will no longer be required. It is important to note that only some states have chosen to expand their Medicaid coverage and change their eligibility requirements through the ACA; others are still deciding.
Medicare is a government-sponsored insurance program for people over 65 and those who are disabled (with a work history) or blind. Part D of Medicare pays for medications. The ACA will gradually close the gap in Medicare's prescription drug benefit (Part D) known as the "doughnut hole." The doughnut hole refers to the amount between total drug costs (what you and your plan spend in drugs) and a person's total out-of-pocket spending maximum for the year (this includes any co-pays, co-insurance, and deductibles). In addition, ADAP payments for prescription drugs are now considered contributions toward the True Out of Pocket Spending Limit (TrOOP) for Part D, which means that people can move through the doughnut hole more quickly.
For more information on ADAPs, Medicaid, and Medicare, see the Health Benefits section of The Well Project's Public Benefits and HIV in the US article.
If you do not have access to insurance offered by an employer or do not qualify for Medicaid, you can look for affordable health insurance through the health insurance marketplaces. These marketplaces for individuals and families are available either through your state, if it chose to set up a marketplace, or through the federal government, if your state chose not to participate. Click here to learn more about enrolling in the federal marketplace.
For those who have trouble paying, there are federal tax credits and subsidies (money the government gives you) for people with low and middle incomes to help make the insurance premium more affordable.
Drug companies run Patient Assistance, Expanded Access, and Compassionate Use Programs. Each company has its own rules for deciding how the program works. Your health care provider will need to complete applications in order for you to apply.
Patient Assistance Programs help people get medications that are already approved by the US Food and Drug Administration (FDA). If you qualify for the program, you will be able to get your HIV drugs without cost. Patient Assistance Programs are usually a short-term solution until another way of paying for the drug is arranged. However, this can be helpful if you are waiting for insurance or government benefits to begin.
Expanded Access and Compassionate Use programs provide drugs that are not yet FDA-approved to people who are in serious risk of illness or who have no other way to construct a good treatment regimen. The drugs are provided free of charge by the companies developing them through participating health care providers.
A company will often create an Expanded Access Program just before the drug is about to be accepted by the FDA. The rules are the same for everyone using the program, while with Compassionate Use Programs, each case is looked at individually.
In some cases, you can get HIV drugs free of charge through a clinical trial. However, drugs being tested in clinical trials may not be FDA-approved, so there is some risk involved in taking an experimental treatment. You will also need to meet the entry requirements of a trial in order to be allowed to participate and you may not have control over which drugs you receive.
Clinical trials are important because they determine if a drug is safe and effective. Some HIV drugs affect women's bodies differently than men's. If you take part in a clinical trial, you will help people know more about how HIV and HIV drugs affect women.
Being in a trial can mean answering extra questions and taking more time at your provider's office or clinic. Before joining a trial, make sure that it is the right decision for you. If you are joining primarily to have access to HIV drugs, speak to your health care provider and get all the facts before relying on this method to get your drugs.
Buyers' clubs sell complementary treatments and supplements, at prices generally lower than retail. Many of them are nonprofit and some offer financial assistance if necessary. If you use supplements, buyers' clubs can help cut costs.
Some community organizations have money to help people in an emergency get the drugs they need on a short-term or one-time-only basis. Your local AIDS service organization (ASO) may have a program that can assist you while you are waiting for insurance or government benefits. Click here to find an ASO in the US. To find services across the world, visit AIDSmap's e-atlas.
Do not take a friend's drugs even if they are the same as yours. Your friend will run out early and may not be able to get the prescription refilled. In addition, it is best to take only drugs that were meant for you.
If you are having trouble getting your HIV drugs, talk to your health care provider before you run out. He or she may have samples of drugs that will last you until a prescription program starts.
It can be awkward or embarrassing to ask for help. However, taking your HIV drugs is the key to living a long, healthy, and productive life with HIV. If you cannot afford your HIV meds, it is important that you ask your provider, treatment advocate, case manager, or representative from a local AIDS service organization to help you find short- and long-term options for getting the HIV drugs you need to stay healthy.