Medicare Part D: Prescription Assistance Options
There are two types of prescription drug assistance programs, apart from the Part D Low
Income Subsidy (LIS/Extra Help), which may help your clients access their prescriptions
and pay for their drug costs:

  • State Pharmaceutical Assistance Programs (SPAPs)
  • (Private) Pharmaceutical Assistance Programs, or Patient Assistance Programs (PAPs)

State Pharmaceutical Assistance Programs (SPAPs)
SPAPs are state-administered programs that help people with limited income and resources with their prescription drug costs. Many SPAPs work with Part D plans, and “wrap around,” or fill in the coverage gaps, of your client’s Part D coverage, such as paying for drugs not covered by your client’s plan. However, not every state has an SPAP; as of September 2015, 19 states and the U.S. Virgin Islands offer an SPAP. Because each state runs its own program, each SPAP is different. For example, some SPAPs only assist individuals with certain chronic conditions, such as HIV or renal disease.

If your state has an SPAP, find out more about what it covers, and the eligibility requirements. People enrolled in an SPAP also have the added benefit of getting one Special Enrollment Period (SEP) to use once per calendar year. And remember, SPAPs, like Medicaid, are always the payer of last resort.

Elderly Pharmaceutical Insurance Coverage EPIC

Pharmaceutical Assistance Programs, or Patient Assistance Programs (PAPs)
PAPs are private programs offered by drug companies, and like SPAPs, help people with limited incomes pay for their prescription drugs. However, unlike most SPAPs, some PAPs do not help clients who already have insurance (such as Part D), or who already get prescription assistance (LIS/Extra Help). Many drug manufacturers offer the drugs they make for free, or at a discount. Because each drug company runs its own program, each PAP is different and different companies call their PAPs by different names. Some PAPs cover only a few medicines made by a particular company; others include all of the prescription drugs that the company offers.

Generally, to apply for any PAP, your client must fill out an application and get his or her doctor to sign it. If your clients take medicines from more than one company, they will need to apply to the PAP of each company that makes their drugs.

If your client qualifies, some programs will give medicines for free. Others will charge a small fee. The company will send the medicines to your client’s home, pharmacy, doctor’s office, or health clinic. Keep in mind that the assistance provided by the PAP does not count toward your clients’ TrOOP (true out-of-pocket) costs; however, the nominal copayments that your client pays (to the PAP) do count. Your client will need to submit a receipt to the drug plan to make sure it gets applied.

Patient Assistance Program (PAP) Tips
Some helpful hints to help you help your clients:

  • Find out whether a PAP is offered by the manufacturers of specific medications.
  • Search manufacturers’ requirements regarding PAPs that work with Medicare
    coverage.
  • By answering a few questions, you can screen your clients for Extra Help, SPAPs,
    and PAPs. Visit BenefitsCheckUp® and click on “Get Started Now” or “Find Help
    Paying for Prescriptions” to get started.
  • Through a toll-free number (1-888-4PPA-NOW) and website (www.pparx.org), the
    Partnership for Prescription Assistance provides a single point of access to more than
    475 public and private patient assistance programs that could offer help on more
    than 2,500 prescription medicines.
  • Since some PAPs require an LIS/Extra Help denial letter before helping Medicare
    beneficiaries, consider advising Part D enrollees who might need PAP assistance to
    apply for LIS. While getting an LIS/Extra Help denial letter may create work and
    may delay the process, patients may qualify for LIS/Extra Help and in any event it
    might be the best strategy in the long run.
  • It might take some time for a PAP application to be processed and medicine to be
    sent out. Many PAP programs have medicines sent to the patient’s home or the
    physician’s office, or the medicine may be available at the pharmacy. Each PAP is
    different.
  • Remember that applications generally need prescriber information and a signature.
  • When PAP eligibility is denied, the applicant may be able to submit an appeal. While
    there is no single standard appeals process, the American Society of Health Systems
    Pharmacists advises that:

    • Companies may accept an appeal letter or a letter of medical necessity from
      the physician that accompanies the application explaining the extenuating
      circumstances of the financial hardship that purchasing their needed
      medication would cause. These are considered on a case by case basis.