Pamela Yip
pyip@dallasnews.com - For consumers who can’t afford to pay for medications, the struggle can be literally a matter of life or death.
The good news is, you don’t have to go without your meds. Help is available through major drug companies’ patient assistance programs.
These programs offer free or low-cost drugs to uninsured individuals who can’t afford their medications. Most brand-name drugs are found in these programs.
Patient assistance programs have been a godsend for Dallas resident Hobert Haggerty’s elderly parents, who live on a fixed income. Her father and mother each take several medications a day.
“I am so thankful for the program,” she said. “It’s helped because the medications are so expensive — $300 or $400 for a 30-day supply gets expensive.”
Each drug company has its own rules about who qualifies for its assistance program, but generally, you must be a U.S. citizen or legal resident, have no prescription drug coverage and meet certain income requirements.
“Generally, the income criteria will range from 200 percent of the federal poverty level to 400 percent of the federal poverty level, and there are instances where it could be higher,” said Tracy Foster, president of Lash Group, which administers patient assistance programs for pharmaceutical firms.
Recipients of Medicare’s Part D prescription drug benefit aren’t necessarily disqualified. In fact, most major drug companies have provisions for Medicare patients to qualify, Foster said.
“It is sometimes under a special program and may require a special application,” she said. “It sometimes requires that a patient already have spent a certain amount of money under their Medicare Part D benefit to qualify.”
Pfizer Inc. helps Medicare patients through “hardship exceptions,” said Gary Pelletier, director and team leader for Pfizer Helpful Answers, a group of programs that help the uninsured and underinsured get access to the company’s medicines for free or at a savings.
“They have to meet income eligibility criteria,” he said. “When they qualify for a hardship exception, we will give them the medicine for free through the end of the calendar year. We provide that entirely outside of the Medicare Part D benefit.”
The patient assistance programs can be of particular benefit to the millions of workers who have lost their jobs since the economic downturn.
Although it doesn’t collect employment data, Merck said its patient assistance program has seen a 50 percent increase in enrollees over the past three years, said spokeswoman Kelley Dougherty.
And Pfizer launched its MAINTAIN (Medicines Assistance for Those who Are In Need) program for the unemployed in 2009 “in response to the economic crisis,” Pelletier said.
“Many of the manufacturers have responded to increasing need by reassessing their income criteria,” Foster said. That has helped more patients qualify for assistance.
“Over the last three to five years,” she said, “we have seen manufacturers increase the [income] limit, so they’re accepting patients at higher income levels and acknowledging that there are just greater financial hardships generally speaking, given the economy.”
Here’s what you need to know about these programs:
Talk to your doctor
“Most of the applications for assistance need doctor participation,” Foster said. “It will also require a prescription or doctor’s signature saying the patient is actually being prescribed the medication they’re seeking help for.”
Make it as easy as possible for the doctor’s office.
Fill out as much of the application as you can. Highlight the directions for the doctor and where he or she needs to sign. Give the doctor’s office an addressed-and-stamped envelope to send in the application or highlight the fax number so it’s easy to find.
“A lot of times, it’s good to have a contact at the doctor’s office,” said Amy Zubrzycki, director of the Senior Prescription Assistance Program at the Senior Source, a Dallas-based nonprofit. “They can help speed up that information to the doctor, getting it signed and getting it back to you.”
Don’t rush it
Most programs have income criteria, and you must provide proof of income. Foster said if you’ve lost your job, include an explanation in your application that says, “Here’s my previous year’s tax documentation, but I am currently unemployed.”
Read the application instructions carefully and be sure you understand them and follow them precisely.
“What can slow down the process sometimes is there’s missing information on the application or missing paperwork,” Pelletier said.
Some programs are fussy about their applications, according to NeedyMeds, a nonprofit information source that helps people find patient assistance programs.
“The directions on the application should be completed exactly as directed,” the organization said. “Print neatly. If something is unreadable or there is a blank, then the application may be denied, which can delay the process of receiving the medicine.” Put “N/A” or “not applicable” in blanks that aren’t filled out to indicate that the material was read through and not skipped over, NeedyMeds said.
Plan ahead
Plan ahead so your medicine supply doesn’t run out, NeedyMeds said.
“When sending in an application, pay attention to the refill process and the amount of allowable refills,” the organization said. “Each program is different. Some may require a call from the doctor’s office, while another may allow the patient to call directly for a refill. Others may require a new application, which takes time.”
Ask questions
Call the patient assistance program if you have any questions.
“Eligibility requirements, drugs, dosages, even programs change regularly, so it’s best to go directly to the program for information,” NeedyMeds said. “If you do not qualify for the program but cannot afford the medicine, then tell the representative. Some companies may make hardship exceptions and are willing to review situations on a case-by-case basis.”
You can also ask your doctor to write an appeal letter explaining your financial hardship.
So don’t let hard times force you to choose between paying for medications and other essentials for your survival. Take advantage of patient assistance programs.
Aid resources
Here are some sources of information on patient assistance programs and how to contact them:
NeedyMeds is a nonprofit information resource that helps people in need find patient assistance programs. It’s a source of information on thousands of programs that may be able to offer assistance to people in need. needymeds.org.
The Partnership for Prescription Assistance helps qualifying patients without prescription drug coverage get the medicines they need for free or nearly free. The PPA is sponsored by pharmaceutical research companies. pparx.com or 1-888-477-2669.
The Senior Source provides a Senior Prescription Assistance Program that helps seniors in Dallas and Collin counties apply for free or low-cost medications through the indigent drug programs of various drug companies. www.theseniorsource.org/pages/prescription_drugs.html or 214-823-5700.
Extra Help is a program provided by Medicare to help those with limited resources and income pay for monthly premiums, annual deductibles and prescription co-payments related to a Medicare prescription drug plan. ssa.gov/prescriptionhelp or 800-633-4227
RxAssist offers a comprehensive database of patient assistance programs and is part of the Center for Primary Care and Prevention at Memorial Hospital of Rhode Island. rxassist.org.
Rx Outreach is a nonprofit organization that offers prescription medicines to uninsured individuals and families, as well as those who have limited prescription drug coverage. rxoutreach.org.
https://nwpf.org/stay-informed/news/2012/02/help-for-those-who-cant-afford-medicines/
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Government Benefits and Insurance
The U.S. government provides benefits and care coverage to those in need. On this page we outline some programs that may help people living with Parkinson’s disease. Remember to keep any potentially relevant paperwork you receive from an employer, an insurer, a government agency or an advocate on your behalf and to keep copies of everything that you submit.
Social Security
Social Security Disability Insurance (SSDI)
If you live with Parkinson's disease, are below 65 years of age and are unable to work due to your Parkinson's disease and/or other condition, you might be entitled to SSDI benefits. These are income supplements for people whose employment is limited due to a disability. Read more about SSDI or call 1-800-772-1213 to learn more.
It can take a few months for SSDI to kick in. During that period, applicants may be eligible for Supplemental Security Income (SSI) benefits from the government.
SSDI beneficiaries are automatically eligible for Medicare after collecting SSDI benefits for 24 months. They may also be eligible for Medicaid but must submit a separate Medicaid application. See below for more information on those programs. For further information, read the Social Security guide to Medicare.
Supplemental Security Income (SSI)
SSI provides a monthly cash stipend to people with disabilities who need help meeting their basic needs for shelter, food and clothing. It differs from SSDI in that it is based on financial need only. Read more about SSIor call 1-800-772-1213 to learn more.
People diagnosed with multiple system atrophy, a type of parkinsonism, may qualify for a fast-tracked application under the compassionate allowances condition initiative, which is reserved for applicants whose medical conditions almost always meet Social Security's disability standards.
Revised Rules for Determining Eligibility
Beginning September 29, 2016, the Social Security Administration (SSA) will be using new criteria to evaluate Parkinson’s disease for disability insurance. This marks the first time the SSA has incorporated the non-motor aspects of Parkinson’s disease, such as cognitive functioning, into its criteria for evaluating SSDI applications.
Medicare
Medicare provides health care services for people 65 and older and people younger than age 65 with disabilities. There are several components to Medicare:
- Part A covers inpatient hospital stays, skilled nursing facility stays, home health visits (also covered under Part B) and hospice care
- Part B covers physician visits, outpatient services, preventive services and home health visits
- Part C refers to the Medicare Advantage program, through which beneficiaries can enroll in a private health plan and receive all Medicare-covered benefits
- Part D covers both brand-name and generic prescription drugs; this coverage is provided through third-party companies known as prescription drug plans (PDP)
- Medicare supplement (Medigap) is insurance sold by private companies that can help pay for some health care costs that Medicare does not cover
Medicare Therapy Caps
The Balanced Budget Act of 1997 created limits, or caps, on the amount of outpatient physical, occupational and speech-language therapy a Medicare beneficiary can receive each calendar year. There is currently a combined $1,940 yearly cap for physical therapy and speech-language therapy, and a separate $1,940 yearly cap for occupational therapy. Once those amounts are reached, beneficiaries who require additional services in the calendar year are responsible for 100 percent of the cost. In addition to the caps, a manual medical review is required once a beneficiary hits $3,700 in therapy services.
To mitigate the impact of these caps, Congress created an exceptions process for services deemed medically necessary. If care continues to be medically necessary beyond the $1,940 cap, ask your therapist to:
- Apply a KX modifier to the therapy code to show the use of the therapy cap exceptions process.
- Submit documentation that supports the medical necessity of continuing therapy. The documentation should indicate why the patient requires continued skilled therapy as the absence of this information may result in Medicare's decision to deny claims for these services.
The exceptions process is temporary and must be reauthorized by Congress every year. In 2015, Congress passed a two-year extension of the exceptions process that expires March 31, 2017.
Medicaid
Medicaid is a joint federal-state program that provides health care services primarily to low-income individuals. Among those potentially eligible for coverage are people with disabilities and those who receive federally assisted income maintenance payments, such as Supplemental Security Income (read more on that program above). Because state governments contribute a substantial amount of funds to Medicaid, benefits vary widely around the country. Nearly all programs help pay for prescription drugs.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
The Consolidated Omnibus Budget Reconciliation Act (COBRA) stipulates that when an employee loses health care coverage under an employer-sponsored plan, he or she can elect to continue coverage under that plan for a set period of time on a self-pay basis. COBRA applies most frequently in instances when an employee is laid off (for reasons other than "gross misconduct") or his or her hours are reduced. The law also applies to the employee's dependents in the event of divorce, the employee's death or other situations.
Generally, employers are required to offer access to their health care plan for 18 months after the employee is terminated or his or her hours are reduced. That period is extended to 29 months for an individual who is determined to be disabled under the Social Security Administration guidelines.
Veterans and Parkinson's
In 2001, the Department of Veterans Affairs (VA) created six specialized centers known as the Parkinson's Disease Research, Education and Clinical Centers (PADRECCs). These centers serve veterans affected by Parkinson's disease through state-of-the-art clinical care, education and research. Each PADRECC services a large geographic area and is staffed by movement disorder specialists, neurosurgeons and other Parkinson's disease experts who assist veterans in managing their disease.
In order to serve veterans diagnosed with Parkinson's disease nationwide, the PADRECCs created the Consortium Centers, which offer specialized Parkinson's disease and movement disorder specialty care to veterans who cannot travel to a PADRECC. Currently, 51 Consortium Centers work collaboratively with the PADRECCs to ensure the highest level of care for all veterans.
Traumatic Brain Injury
In December 2013, the VA finalized a regulation that makes it easier for some veterans with moderate or severe traumatic brain injury (TBI) who also have parkinsonism, including Parkinson's disease, to receive additional disability pay. This regulation impacts veterans living with TBI who also have Parkinson's disease, certain types of dementia, depression, unprovoked seizures or certain diseases of the hypothalamus and pituitary glands. If a veteran had a moderate or severe TBI as a result of service and also has Parkinson's, then the Parkinson's will also be considered service connected for the calculation of VA disability compensation.
Agent Orange
In 2010, the VA recognized Parkinson's disease as associated with exposure to Agent Orange or other herbicides during military service in Vietnam. Veterans who develop Parkinson's disease and were exposed to Agent Orange or other herbicides during military service do not have to prove a connection between their disease and military service to be eligible to receive VA disability compensation. Veterans diagnosed with Parkinson's disease who served in-country or on the inland waterways of Vietnam between January 9, 1962, and May 7, 1975, are presumed exposed to Agent Orange or other herbicides.
This decision was based on an Institute of Medicine report, " Veterans and Agent Orange: Update 2008 ,” which stated there was "suggestive but limited evidence that exposure to Agent Orange and other herbicides used during the Vietnam War is associated with an increased chance of developing Parkinson's disease.”
Other Disability Policies
Many employers offer short-term and/or long-term disability plans that employees can choose to put money into while they are working. After leaving work because of a disability, qualified employees receive a portion of their salary while they are disabled. Private-sector plans usually begin paying out within a period of months after a disability begins. That compares favorably with most government disability programs, which can take a year or more to approve a disability claim and begin disbursing payment. Some private plans pay a set amount regardless of what an insured patient receives from Social Security, while other plans may offset the benefits they pay by whatever disability payments the insured may receive from Social Security.
Congressional Assistance
Members of Congress can provide assistance to constituents who are applying for government benefits. Your senators or representative may be able to help with:
- Tracking a misdirected benefits payment
- Filling out a government form
- Applying for Social Security, veterans’, education and other federal benefits
In some cases, your senators or representative may be able to help expedite a Social Security disability claim. Your elected official can open a congressional inquiry into the status of your claim and it may result in your application being processed sooner.
It is important to note that a congressional inquiry does not affect the SSA’s final decision regarding your eligibility for disability benefits.
To request assistance from your member, contact their office and explain what government benefit you are applying for. They may ask you to submit additional documentation or complete forms through their website.
Additional Resources
The Assistance Fund's mission is to provide critically or chronically ill individuals with access to advanced therapies through a continuum of services and programs, including covering medical and prescription costs.
Consumer Reports Best Buy Drugs provides information to consumers on the costs of prescription drugs.
This site offers prescription drug price comparisons and free coupons for consumers.
MWPF offers assistance to individuals with Parkinson's disease who are struggling with financial issues to help pay for a home health aide, visiting care or to purchase specified medical equipment.
This organization provides a number of resoucres to help older adults improve their health and well being, including information on how to prevent falls.
This site provides information about assistance programs available to low-income patients and their advocates.
This program's mission is to increase awareness of patient assistance programs and boost enrollment of those who are eligible.
This foundation provides assistance to people with Parkinson's disease who have financial need.
This nonprofit organization solves insurance and health care access problems by acting as a liaison between patients and insurers, employers and/or creditors.
This website is provided by The American Elder Care Research Organization to help people with Parkinson's with financial need find additional resources.
RxAssist offers a comprehensive database of pharmaceutical companies' patient assistance programs and provides practical tools, news and articles.
Rx Outreach is managed by Express Scripts Specialty Distribution Services, Inc. (ESSDS), a fully-licensed mail order pharmacy. The program offers prescription medicines to uninsured individuals and families, as well as those who have limited prescription drug coverage.
https://www.michaeljfox.org/understanding-parkinsons/living-with-pd/topic.php?government-benefits
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Prescriptions Assistance
- https://panfoundation.org/index.php/en/patients/assistance-programs/parkinson-s-disease
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- https://www.benefitscheckup.org/find-help/
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- http://ww2.aaa.com/scripts/WebObjects.dll/AAAOnline?page=AAAPrescriptions&association=aaa&club=020&zip=60187&stateprov=il&city=wheaton&devicecd=PC&referer=discounts.aaa.com
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- http://healthtools.aarp.org/pill-identifier
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- http://www.mwpf.org/apply-for-help/
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http://www.apdaparkinson.org/young-onset-links/young-onset-prescriptions/
Other:
https://www.helprx.info/conditions/parkinsons
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