Can't afford my medication!!!

[papichasing]

Ive been taking Atripla since I found out about my condition 8 years ago. My health insurance (United Health Care) was taking care of most of my bills and thanks to my Copay Card I was getting my prescriptions for free. Today when I went to get my monthly supply I was informed that my insurance company will be covering only 50% of the bill. That leaves me with an amount of $1500.00 to be paid from my pocket every month. A total of $18,000 every year!!! My salary is only $22,000 a year!!! I am not familiar with all the health insurance procedures or policies and honestly I am desperate at this moment. I can't afford to pay $1500 every month!!! Im hoping that someone here can give me any advice of what to do or how to get any help on this matter. I am scared to death at this moment. Please, any advice will be more than appreciated. Thanks in advance for your help.

[AusShep]

Hopefully you have enough of a backup supply at this point to get things worked out.  Others may be able to offer some govt/ASA assistance info.

What is your out of pocket max for the year?  The highest it can be is about $6500.

I'd try to get your Dr to switch you to Truvada and Tivicay, so you can take advantage of two copay programs.

Tivicay will apply however much you need up front, I actually got an entire month for free last year during an insurance mix up.

I've heard that as of November, Gilead will now do the same with Truvada vs a $400/month cap.

My costs on UHC are $1480 for Truvada, and $1328 for Tivicay.  So, if everything works right, using both of those plans together should get you to your out of pocket max for the year without any expense on your part if they both cover the about $700 month needed.  I believe they both credit enough to take care of 5 payments, which will take you to your max for the year.

Hope this helps/works.

[papichasing]

Thanks for your reply. I will be calling my doctor tomorrow to see what are my options. I have to admit that I was desperate. Can you imagine if out of the blue you find out that you basically will have to spend your yearly income to pay for a single medication? I've been also checking into the possibility of getting the generic Atripla what I can get on line for as low as $130.00 for a 30 days supply. I need to talk to my doctor about that option since I am not 100% sure if I can trust this online companies. And I will definitely  tell my doctor about your advice on switching to Truvada and Tivicay. After having a VERY emotionally and mentally rough day I feel more calm now looking to my other alternatives. I only have 2 pills left but I have a very good friend who is going to help me with a supply until I can find a solution to this problem. Thanks from the bottom of my heart for your reply and advice. It means a lot to me my friend!

[AusShep]

No problem.  I hope it works out.
I'd be wary of the online generics, there was a post not too long ago from someone taking them whose viral load went way up on them, probably because they were fake.  If I find the post I'll link it.

Here it is: cd 4 fell from 700 to 400, VL up to 80000
http://forums.poz.com/index.php?topic=60809.msg691166#msg691166

[GoForIt]

Hopefully you have enough of a backup supply at this point to get things worked out.  Others may be able to offer some govt/ASA assistance info.

What is your out of pocket max for the year?  The highest it can be is about $6500.

I'd try to get your Dr to switch you to Truvada and Tivicay, so you can take advantage of two copay programs.

Tivicay will apply however much you need up front, I actually got an entire month for free last year during an insurance mix up.

I've heard that as of November, Gilead will now do the same with Truvada vs a $400/month cap.

My costs on UHC are $1480 for Truvada, and $1328 for Tivicay.  So, if everything works right, using both of those plans together should get you to your out of pocket max for the year without any expense on your part if they both cover the about $700 month needed.  I believe they both credit enough to take care of 5 payments, which will take you to your max for the year.

Hope this helps/works.

I heard the Tivicay copay card pays up to 6k for the year.  So you were able to use the card to get 1 bottle free basically and it went towards your deductible?

[AusShep]

I heard the Tivicay copay card pays up to 6k for the year.  So you were able to use the card to get 1 bottle free basically and it went towards your deductible?

Yes, but I was switched back to my 0 copay plan the next month, and I think I remember seeing an amount applied, but I can't verify 100% as my Rx records are now all gone from my old insurance website, but that is how others report the mfg copay programs work for them.

[GoForIt]

What is the reason you switched to all copay?  I think I calculated its more expensive with all copay plan if you are going to use the copay card from ViiV or GILD no?

[BT65]

Papichasing,
Have you ever contacted the nearest ASO (Aids service organization) in your area?  They have caseworkers there that assist with your issue.  I used to be a caseworker at the ASO here, and I helped people get co-pay assistance quite often.  I would definitely contact them and talk to someone. 

Betty

[AusShep]

What is the reason you switched to all copay?  I think I calculated its more expensive with all copay plan if you are going to use the copay card from ViiV or GILD no?

It was a $0 Rx plan, 100% paid for all tiers; they're not common.  Got switched to a high deductible plan, it was fixed in a few days, but not active again till the first of the next month. Which left me using a month of surplus vs paying $1000 out of pocket, $400 Truvada copay card, and fighting to get reimbursed.  I had a few months extra, so took the easier route after spending 2 days on the phone to get the plan fixed and just filled the Tivicay and used surplus for Truvada.

[GoForIt]

My question is, when you use the copay card for Tivicay which can cost (1,300 per 30 days) did it count toward your deductible?

[papichasing]

I just got a message from my pharmacist letting me know that he was able to get me some copay assistance and my balance to get the medication is back to $0.00. Every once in a while you have the chance to meet a living angel and this man is one of them. He has been there to help me many times and always goes beyond my expectations. I am soooo relief now. Thanks you all for your replies. And God bless each one of you.

[Jeff G]

I learned a long time ago to be nice to your pharmacist ( Im always nice anyway ) they can do more quicker and than your doctor if its in their power and will to do so. The same goes for your nurse, the support staff around your doctor are the ones who get things done.

[mitch777]

Hi Papi,

I haven't been keeping up here lately but read this thread and was wondering why nobody has mentioned ADAP.

It seems to me that you would qualify in every state (?) with your income. Each state is different but I would suggest you do a Google search for the eligibility requirements for where you live.

ADAP covers my HIV med co-pays as well as most of my other meds with very few exceptions. ADAP can be used in conjunction with your current insurance and co-pay assistance cards as far as I know.

[Mightysure]

I know this is a bit late, but try www.panfoundation.org They usually approve you over the phone. 4k grant and will generally grant you a second one in a year.  With the copay assistance from Gilead and PANF, you should reach your out of pocket max and your insurance company should pay at 100% afterwards.

ADAP probably wouldn't be the best option because not only is the application process hell on earth, they may not cover you since you're insured. They may have a copay assistance sub-program like they do in North Carolina, but it's not for emergency situations generally.

[BT65]

If one gets in touch with a case worker at an ASO, the worker usually fills out the ADAP application; I know I did when I worked at an ASO.  The only thing the client had to provide was a copy of their ID and proof of finances.  So, I don't know why MIghtysure thinks it's hell on earth.  That isn't usually true.  Not that I know every state's requirements but I bet a caseworker at the ASO would fill out the paperwork.

Betty

[Mightysure]

If one gets in touch with a case worker at an ASO, the worker usually fills out the ADAP application; I know I did when I worked at an ASO.  The only thing the client had to provide was a copy of their ID and proof of finances.  So, I don't know why MIghtysure thinks it's hell on earth.  That isn't usually true.  Not that I know every state's requirements but I bet a caseworker at the ASO would fill out the paperwork.

Betty

Because in North Carolina it is.  I'm glad it wasn't for you, but the legislature doesn't want people on it, so they've purposefully made it difficult.

[Jeff G]

Because in North Carolina it is.  I'm glad it wasn't for you, but the legislature doesn't want people on it, so they've purposefully made it difficult.

I never had a problem when I needed ADAP in Alabama. If you qualify you get services.
What specifically do you think is hard about it ? ASO’s are in the business of helping people access services and do not put any more demands on the client than the rules require.

I have heard stories of inefficiency in select offices .

[BT65]

Because in North Carolina it is.  I'm glad it wasn't for you, but the legislature doesn't want people on it, so they've purposefully made it difficult.

Just for the record, I have never been on ADAP myself.  But when I was a caseworker I would fill out the paperwork for people who needed the program, and it didn't take long for the person to be approved as long as all the requirements were met.  Usually the only thing the clients had to provide was proof of identity (copy of license, ID, visa) and proof of income.  If one didn't have an income he/she would have to go to the unemployment office and get a printout which showed that the person was not employed.  And I would take them there so I could tell the person working at the unemployment office exactly what the client needed.  Oh, and if the person claimed more people living in their home, they had to provide proof that the person they were claiming actually did live with them.  If the person was a minor that would usually mean my client would provide the birth certificate. If the person was an adult, the client usually had them provide a copy of their picture ID which would show the same address.  And if the client couldn't find the minor's birth certificate, they could use something showing the minor lived at their address like a document from the school etc.  A client only did this if their income was too high for one person.  I even had a client whose income was so high we had to say she had a couple of her kids living with her that actually lived with the other parent.  Luckily the kids used to live with her so we were able to find letters from the school showing the her address as the children's address. 

Yes, we did sometimes fudge paperwork so the client could receive services as just because their income was too high for one person to receive ADAP, that didn't mean they could afford their medical treatment and meds.  So we made sure the person could access this program.  That's how it usually works, at least in Indiana.  I have to admit, though I do not like Indiana's governor or state politicians and their homophobic agenda, Indiana does take pretty good care of its HIV+ citizens.

Even if someone is undocumented, they can access certain programs that would pay for their doctor visits, labs, dental, vision, and medications. 

I do not believe it is that difficult to access ADAP in most states as long as the person who needs it gets in touch with the ASO in their area and provides the documents needed.  I of course could not promise that since I haven't lived in all 50 states, but I would guess that it is a bit uniform across the board.

Betty

[Mightysure]

I'm grateful that ADAP is easy in other jurisdictions.  It's more cake walk here.  OP,  I hope you obtained your medication and you live in a state that wants to help. 

[LiveWithIt]

Go apply for Ryan White and if you don't qualify then maybe ADAP can help you.

[Jeff G]

Go apply for Ryan White and if you don't qualify then maybe ADAP can help you.

When you tell someone to go apply for Ryan White, its essentially saying the same thing as go apply for ADAP.

From Kaiser
Ryan White and ADAP …ADAPs began serving clients in 1987, when Congress first appropriated funds to help states3 purchase the only approved antiretroviral (ARV) drug at that time, AZT. In 1990, they were incorporated into the newly enacted Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, now known as the Ryan White Program.4,5  Since Fiscal Year (FY) 1996, Congress has specifically earmarked funding for ADAPs through Part B of Ryan White, which is allocated by formula to states.6 Ryan White has been reauthorized by Congress four times since first created and changes have been made to ADAPs over time.

In FY 2013, 59 jurisdictions received ADAP earmark funding; 51 reported data, including 47 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands.  ADAPs also receive state funding and contributions from other sources, including other parts of Ryan White, but this support is highly variable and largely dependent on local decisions and resources.  ADAPs are not entitlement programs; annual federal appropriations and, where available, other funding, determine how many clients ADAPs can serve and the level of services they can provide.  Each state operates its own ADAP, including determining eligibility criteria and other program elements, resulting in significant variation across the country.

[leatherman]

although this is not quite on-topic, it's never a bad time for some education
especially when so many of us in the States use these services to stay medicated and healthy.

Go apply for Ryan White and if you don't qualify then maybe ADAP can help you.

The Ryan White Care Act is divided into several "Parts":

Part A gives emergency assistance to EMAs (Eligible Metropolitan Areas) and TGA (Transitional Grant Areas) that are most severely affected by the HIV/AIDS epidemic. These are bulk grants to areas where the rate of HIV infection is rising and allow extra spending in various areas to expand services to care for the growing population of PLWH

Part B provides grants to all 50 States, DC, and the territories. ADAP (AIDS Drug Assistance Program) is a component of Part B

Part C provides comprehensive primary health care in an outpatient setting for people living with HIV disease.

(Part B and C provide the bulk of Ryan White services to the majority of clients. Part A supplements these other Parts. Most ASOs (AIDS Service Organizations) that do not provide medical care use Part B to provide prevention services and case management; while medical services are funded through Part C for those "one stop shops" that have on-site doctors, PAs (physician assistant), or NP (Nurse Practitioner)

Part D provides family-centered care involving for women, infants, children, and youth with HIV/AIDS.

(Part D is slowly being phased out. As more ASOs change into FHQCs (Federally Qualified Health Centers), children, women and infants are now getting their services through these community health clinics along with those who receive Part B and C services.)

In the past each of these Parts operated within their own spectrum while the state health department and HPC (HIV Planning Council) or a Quality Committee coordinate services and grant proposals to provide a state-wide approach to dealing with HIV. Since the National HIV Strategy for 2016-2021 directs the Ryan White Parts to better coordinate, we'll be seeing more and more partnership between the Parts and hopefully even better plans for statewide HIV prevention and healthcare

bonus info!
HOPWA (Housing Opportunities for People With AIDS) is not a RW service, but is a program of the US Department of Housing and Urban Development (HUD) that provides funding to support housing for PLWHA and their families.

more information is available at the HRSA (Health Resources and Services Administration) HAB (HIV/AIDS Bureau) (which is the federal agency which administers the RW program) website
http://hab.hrsa.gov/abouthab/aboutprogram.html