Prescription Assistance Programs
- Megan Hutton (Unlicensed)
In some cases, we talk to people that have REALLY expensive medications. In certain circumstance, they can qualify for Extra Help/LIS and in some cases, they cannot. If they qualify for LIS, then you can give them the information listed and instruct them on how to enroll, or call with them to help them get the ball rolling (if we are not in AEP or OEP).
If they do not qualify for Extra Help/LIS then provide them with additional resources to help with the cost of expensive medications. If one of the following programs (other than LIS) is going to assist them with a medication, then we do not need to worry about that medication being covered by the plan we recommend. They will be getting that drug through a prescription assistance program.
Sometimes, we talk to a person and the plates tell us that the prescription costs a pretty penny on their current plan, but the shopper says they get it for much less through “something my doctor did for me,” or “through the pharmacy,” or something else that makes ABSOLUTELY no sense. I can almost guarantee that they are receiving that medication at a discounted price through some type of prescription assistance program.
When a shopper is receiving a medication through a prescription assistance program (other than LIS), changing their plan will NOT affect their eligibility for that program and they will continue to receive that medication the same way they normally do, at the same price they normally pay.
Shoppers can always contact the manufacturer of their drugs or contact one of the organizations listed below to see if they qualify for financial assistance with their drugs. Organizations and manufacturers are a lot more lenient than the government. Many organizations, that offer financial assistance, simply require that the beneficiary's income be less than $50,000 per year, or more, in order to qualify for assistance.
SSA – Extra Help/LIS
2022 Income Limits:
$1,232.50/month for Individual
$2,460/month for married couple living together
800-772-1213
7AM-7PM Monday through Friday
Prescription Hope
Offers a wide variety of expensive RXs for $50/month EACH
Income Limits:
An Individual earning $32,000 per year or less.
Households with a combined income of $50,000 per year or less.
Guidelines increase with each additional dependent (3 or more individuals) in households earning a combined income of $100,000 per year or less.
1-877-296-HOPE (4673)
Mon- Fri: 8am - 4pm EST
MERCK
Short list of Rx's but could be as low as $0/month
Includes: Januvia, Janumet, Proventil HFA (most common meds from the list)
800-727-5400
Hours: 8 AM – 8 PM ET
Days: Monday – Friday
Progressive RX
Can serve as a discount program, but it is rare that it will actually save the customer money. To check, simply search for the drugs on the following webpage and compare the prices listed to the copays that the consumer mentioned.
State Pharmaceutical Assistance Programs
SPAPS are only available in certain states. The name of the government program, income levels, and benefits can vary from state to state.
For further information about a certain SPAP, you can google the name of the SPAP or reach out to your supervisor for further assistance.
Medicare.gov prescription assistance search
This is last on the list because it is more complicated than the previously mentioned options, and shoppers are less likely to qualify. When all else fails, check Medicare.gov.
HIV SIDE NOTE: Some states have a separate program for HIV medication, such as Biktarvy, and patients will often get this medication from a local HIV assistance program, rather than through their plan.
For example, Michigan has the Michigan Drug Assistance Program (MIDAP) that provides prescription medication and vaccine copay/coinsurance coverage for qualifying Michigan residents who are living with HIV. Again, not every state is so kind, but a lot of them are.
Do not ASSUME that the shopper will be paying the full cost and do not ASSUME that the shopper will NOT be paying the full cost. ASK QUESTIONS to get clarification on the situation before offering a plan!