What are patient assistance programs?

The rising cost of living in the United States is making it harder to pay for prescription medicines, even among individuals with health insurance. For the uninsured or underinsured, high drug costs may mean forgoing a much-needed medication altogether. In fact, more than 1 in 4 Americans struggle to afford their meds, according to a poll conducted by the Kaiser Family Foundation. For some patients, that means skipping doses or simply not taking a prescribed drug, a dangerous situation for those with serious health conditions. 

That’s where patient assistance programs (PAPs) can help. PAPs are programs that help people with no health insurance and those who are underinsured pay for their medications. Here’s how they work.

How do patient assistance programs work?

If you can’t afford your medication, patient assistance programs may be able to help with prescription drug coverage. PAPs give patients without health insurance, underinsured individuals, and beneficiaries with government-funded insurance plans (like Medicare and Medicaid) discounts on their medication, says Stella Bard, MD, a board-certified rheumatologist in McKinney, Texas. Sometimes, the cost of a medication is covered entirely. 

Patient assistance programs are most often sponsored by specific pharmaceutical manufacturers to provide medication they manufacture to patients who are unable to afford their medication, says Brian Staiger, Pharm.D., a clinical pharmacist in Buffalo, New York, and owner of Hello Pharmacist. PAPs are also sometimes offered by government agencies and nonprofit organizations. “Typically, these programs provide medications at little or no cost to those who qualify based on income and insurance status,” Dr. Staiger says.

Unlike copay cards, which are offered by pharmaceutical companies to offset the price of brand-name drugs for patients with commercial insurance, PAPs are intended for those who are uninsured or underinsured and need financial assistance, explains Dr. Staiger. “PAPs all work in the same way, although there are differences depending on the specific program,” he says.

1. A patient or their healthcare provider (in most cases, both) will need to fill out a form to initiate enrollment. 
2. Eligible patients will be required to provide documentation of financial and insurance information to show they have no means of obtaining the medication without assistance. 
3. The healthcare provider very often has to provide evidence of their diagnosis and other patient records as requested.

“After the application is reviewed and approved, the medication is usually shipped directly to the patient’s home or their healthcare provider’s office through contracted pharmacies,” explains Dr. Staiger. He adds that in most cases, the medication cannot be picked up at your local pharmacy. 

Patient assistance program benefits

The primary benefit of PAPs is reduced or no-cost medication to qualifying individuals, says Dr. Staiger, adding that additional benefits may include:

• Insurance premium assistance: Some PAPs help patients with out-of-pocket costs like deductibles and insurance premiums, which are the monthly fees paid to maintain health insurance coverage.
• Medical supplies/equipment: Medical supplies related to the patient’s condition may be provided at little to no cost (e.g., pen needles for diabetics).
• Travel assistance: Some PAPs provide assistance with travel expenses for patients who need to travel to receive medical treatment. 
• Educational resources: Most PAPs provide educational resources such as brochures, videos, and online materials to help patients better understand their condition and treatment options. 

Patient assistance programs drawbacks

There are a few drawbacks to patient assistance programs, Dr. Staiger says. They can be more difficult to find than manufacturer copay cards, and aren’t always transparent in eligibility requirements. In fact, they often have limited eligibility even for patients with very low income. On top of that, most PAPs require the patient’s prescriber to fill out and sign part of the application, making the process more difficult and time-consuming. If a patient needs multiple medications, that requires a separate application for each. 

How do I know if I qualify for a patient assistance program?

The primary eligibility criterion for patient assistance programs is income level. “Every program is different, but most base income limit qualifications in reference to the Federal Poverty Guidelines,” says Dr. Staiger. Aside from income, the following criteria are used to determine eligibility:

• Insurance status: PAPs may only be available to patients who are uninsured or underinsured. 
• Residency: Most PAPs are only available to patients who live in specific states or regions.
• Diagnosis: PAPs generally only cover medications for specific conditions or diseases. Additionally, the drug must be FDA-approved for the condition being treated (i.e., not being used off-label).

RELATED: Off-label prescription drugs: What you need to know

How to register

PAP applications are accessed at the sponsor’s website, which is usually the drug company, advises Dr. Staiger. While some programs will allow you to submit all of the required information online, others require you to print out forms that must be filled out by both you and your provider; some programs can only be initiated via a phone call.

According to Dr. Staiger, the following information usually must be provided:

• Patient demographics
• Income verification
• Insurance information (or verification of lack of insurance)
• Patient attestations to application questions
• Prescriber information
• Prescription information

Patient assistance program examples

Most pharmaceutical companies have a patient assistance program. Examples include:

• GlaxoSmithKline (GSKForYou)
• Gilead (Gilead’s Advancing Access Program)
• Eli Lilly (Lilly Cares)
• Novartis (Novartis Patient Assistance)
• Pfizer (Pfizer Rx Pathways)
• Boehringer Ingelheim (Boehringer Ingelheim Cares)
• Abbvie (myAbbVie Assist)

Nonprofit patient assistance foundations include:

• Healthwell Foundation 
• PAN Foundation

Government PAPs include:

• Medicare Extra Help

RELATED: Who qualifies for Medicare Extra Help? How to apply

How can I find a patient assistance program for my medication?

Here’s how to find a patient assistance program for a particular medication:

• Visit the non-profit organization NeedyMeds website and type in the name of your drug to see if a PAP is available. 
• Visit Medicare’s directory of prescription assistance programs.
• Do an internet search of your medication’s name followed by the words “patient assistance program.”
• Call or visit the drug manufacturer’s website to find out if a PAP is available.