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Having trouble paying for brand-name prescriptions? Work with your doctor to see if you qualify for assistance

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By Dr. Juan Escobar   

As a practicing cardiologist in El Paso, I frequently encounter patients who confide in me that they are unable to afford the medications that I or other treating physicians prescribe for them. This is especially the case for El Paso County residents who happen to be seniors who are living on a fixed income, and also uninsured or underinsured patients, who depend on costly prescription medications for management of heart disease, diabetes, or hypertension. 

Dr. Juan Escobar

While some conditions can be treated with less expensive generic medications, for some necessary treatments there are simply no generic alternatives. These brand name medications that are still protected under patent tend to be much more expensive and carry higher copays with most prescription drug plans. As a public health matter, not being compliant with the prescribed medication can result in long-term adverse effects and additional costs incurred from complications of inadequately treated chronic illnesses.  

Additionally, there continues to be the “donut hole” for Medicare part D recipients that results in a spike in the copays, especially at the end of the calendar year, and cause great financial distress for patients and hard economic choices to be made. 

The available and seldom-used assistance available to all patients is the patient assistance programs (PAP) that all pharmaceutical companies have in some form or another.  These programs offer low cost or free prescription medications directly from the manufacturer to the patients via their treating physician or directly by mail.  

It is important to note that each pharmaceutical company has different eligibility requirements and so the patient and treating physician need to navigate the process to get the benefit. In general, however, to be eligible the patient must be a citizen or permanent legal resident of the United States or Puerto Rico or U.S. Virgin Islands;  prove you are uninsured or that your insurance doesn’t cover your medication; and importantly, meet certain income eligibility requirements.  

My advice is to sign up, contact your treating physician’s office and ask for the medical assistant to help you in the process and investigate which pharmaceutical company is the manufacturer of your brand name medication. In my office, we frequently assist eligible patients in this fashion, along with providing free samples and discount coupons. 

It is important to understand that the coupons are not able to be used by Medicare patients, a frequent misconception. 

Here’s an example of how this works. I prescribe Eliquis (apixaban) for which no generic substitute exists,  for treatment of non-valvular atrial fibrillation and deep venous thrombosis.  That medication is co-marketed by Pfizer and Bristol Meyers Squibb (BMS), both of which have patient assistance programs. Both companies have an 800 number to assist in getting the discount and a website with many details. In the case of  BMS, the income cutoff is 300% of the federal poverty level, adjusted for family size. 

In 2020, for a household size of one, the poverty level is $12,760,  for a household two it is $17,240 and for a household size of three it’s $21,729. So BMS’s cutoff of 300% of the poverty level means that a single individual can make up to $38,280 a year and qualify for assistance; for a family of two, incomes up to $51,720 qualify. Larger family sizes are adjusted accordingly.

 Furthermore, to be evaluated for assistance, patients and their health-care providers must submit a completed enrollment form. Patients must also provide proof of income, such as a W2 form, a paycheck stub, or prior year’s tax return.  It is important to mention that the income and household asset requirements differ between all the companies and needs to be looked at individually. 

In the long term, the best approach will be to pressure elected officials to lower prescription drug prices so that they are more affordable to all patients without the need to resort to complicated patient assistance programs. Until then, I would encourage everyone who is having problems affording their branded prescription medications to investigate whether they qualify for a PAP You may be surprised to learn you qualify.

Dr. Juan Escobar is a cardiologist in El Paso.

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