Prescription drug costs are higher than ever, leaving many patients with few options for affordable medications. Unfortunately, the medications most critical to survival for many suffering consumers are also the most expensive.
Enter drug assistance programs, also called patient access programs or drug access programs. Whatever the name, they all serve the same function: to help patients afford medications they otherwise couldn’t.
These assistance programs come in many forms and scopes, each one different from the next. Some are run by pharmaceutical companies to help patients receive specific medications. Others are independent nonprofit organizations that help patients afford all drugs for a specific disease. It’s clear these programs help thousands of patients each year afford their drugs, but critics say to hold the praise because these programs aren’t all they’re cracked up to be.
Helping Patients in Need
About half of all Americans suffer from conditions requiring medication, according to the Centers for Disease Control and Prevention, and many have a hard time affording them. Due to the cost of those medications, more and more patients report reducing dosage or skipping pills to save money without their doctors’ consent.
But imagine having a condition for which daily medication is the only thing that makes living feasible. “I can’t function without my medication,” says Stephanie Schroeder, a freelance writer and publicist in the New York City area.
Schroeder was diagnosed with bipolar disorder more than a decade ago and prescribed Abilify for management. Luckily, the drug works wonders for her. “It’s like night and day,” says Schroeder, who can become a danger to herself when she’s off Abilify for even a week. When she was first prescribed the drug, it cost $1,300 a month and wasn’t on her insurer’s formulary, or list of covered medications. Abilify currently costs anywhere from $500 to more than $1,000 for a 30-day supply, according to pharmacy comparison website GoodRx.
Schroeder isn’t alone in being unable to afford her medication. For thousands of Americans like her, patient access programs are the only viable way to afford expensive but necessary drugs.
Programs, Foundations Everywhere
For any expensive drug or disease you can think of, an assistance program exists. Many are funded directly by the makers of drugs, such as the Bristol-Myers Squibb program that provided assistance for Schroeder’s Abilify. Those programs cover a portion of the drug, usually equal to the amount insurance won’t cover. In some cases that’s just a monthly copay, and in others it’s the patient’s entire annual deductible.
But getting the assistance isn’t always easy. “Their income threshold changed many times, and my work situation changed a few times, so I’d get rejected all the time. It was a constant battle,” recalls Schroeder, who had to reapply every three months for assistance once she got it, something the program required of all patients at the time. She says she lost count of how many phone calls she made and how many income verification forms she submitted over 10 years to get her Abilify.
Other assistance programs are broader. The Patient Access Network Foundation, for example, aims to help patients with a variety of diseases. “We have 55 diseases for which we offer grants,” explains PAN Foundation CEO Dan Klein. “When a patient receives a grant, the money can be used for any medication or treatment for their disease.
“We’re doing this because patients have nowhere to turn,” he adds. “So many people these days have health insurance with high out-of-pocket costs.” That has become all too common since health care reform, with many patients still experiencing sticker shock — even with insurance.
The income threshold to qualify for PAN assistance is 500 percent of the federal poverty level, Klein says. That amounts to $58,850 for an individual and $121,250 for a family of four in the contiguous United States. In Alaska and Hawaii, the poverty thresholds are higher. Unlike private assistance programs, PAN Foundation funds can also be disbursed to Medicare patients, which represent a large portion of its beneficiaries.
Where the Money Comes From
Except for difficulty getting into assistance programs, they’re largely considered a blessing to desperate patients, but who pays for it all? It seems like the pharmaceutical companies that make the drugs are paying, but all that money winds up back in their own accounts.
“These programs are just a way for big pharma to silence the critics while still making billions in profits,” says Brian Prather, a registered pharmacist and president of Bedford Wellness Pharmacy in Lambertville, Michigan. He works closely with patients, pharmaceutical companies and discount program staffers on a daily basis.
He says insurers still pay for the bulk of the medication’s cost, and the real value goes to them. “The drug company trumpets its humanitarian efforts for the relatively small percentage of patients who are actually eligible and use the program,” he says. By doing this, he adds, it’s “keeping prices sky-high for the insurance companies that pay the majority of the cost.” The result is a drug market where prices go only up and up.
Even more-equitable programs like the PAN Foundation are funded by pharmaceutical companies, though less directly. “Drug companies are the major donors to our foundation,” explains Klein, who says the companies can donate to diseases of their choosing. After that point, however, the pharmaceutical companies have no more say in the application or funding process. Once the money is granted to patients, they’re under no obligation to use it for a specific drug.
As for Schroeder, she’s finally able to afford her medication through other means and no longer has to spend periods of time off her Abilify, which is classified as an antipsychotic but prescribed for a variety of mental conditions, including depression.
This specific drug is an interesting case. In 2013 and 2014, Abilify was the top-grossing drug on the U.S. market, but the 14th most widely prescribed. Abilify sales reached $6.5 billion in 2013 (the most recent total available), making it extremely profitable and leading patients to wonder why its manufacturers don’t just lower the price. “I know it doesn’t have to cost that much,” Schroeder says.
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Drug Assistance Programs: All They’re Cracked Up to Be? originally appeared on usnews.com