4 Tips for Making Your HIV Drugs More Affordable

High Cost of Care Demands an Informed Buying Strategy

Red pill production line
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Affording quality healthcare for the average American is tough enough without the added challenge of a chronic illness. Arguably, for people living with HIV, the challenges are greater given the high cost of HIV drugs, the need for optimal treatment adherence, and the demand for continual, lifelong medical treatment and care.

Consider, for example, that the average, individual lifetime cost of HIV is well over $400,000—and this for persons who start treatment early and largely avoid the illnesses associated with later-stage (or untreated) disease.

Now add to this the cost of HIV therapy, which carries an average price tag of over $2,000 per month, and the obstacles grow even clearer. Even with prescription drug coverage, many of these medications remain unaffordable due to "adverse tiering" practices by which insurers can demand anywhere from 20 percent to 50 percent coinsurance payment for each and every drug prescription.

This means that person with a "low" 20 percent coinsurance benefit could easily pay between $440 to $480 per month to get Triumeq, an otherwise standard, one-pill option. And that doesn’t even take into account the cost of deductibles and other out-of-pocket expenses that could add up to thousands of dollars before your benefits even kick in.

However daunting the prospects may be—particularly for middle-income earners who can neither afford co-payments nor access benefits provided lower income groups—there are remedies.

Some may require you to adjust your current insurance strategy, while others may allow you access to assistance programs that you might have otherwise thought yourself unqualified.

For those seeking relief, here are 4 simple ways to reduce the high costs of HIV treatment and care.

1. Start by Identifying Your Eligibility for Assistance

A popular misconception is that HIV assistance programs are meant to help only the lowest income Americans.

And while it’s true that many federal- and state-run programs limit access to those living at or below the federally prescribed poverty line, it’s not always the case.

Given the hight cost of HIV treatment and care, a surprising number of benefits are available to individuals whose annual income is around $65,000 or families that have an annual income of around $80,000.  This is because benefits are typically provided to those whose modified adjusted gross income is lower than 200 percent to 500 percent of the federal poverty level (or FPL).

To clarify, modified annual gross income (or MAGI) is not the total amount of money you and your spouse make over the course of a year. Rather it is the adjusted gross income (AGI) found on your annual tax return (line 37 on the 1040, line 21 on the 1040A, and line 4 on the 1040EZ) plus the following add-backs:

  • Non-taxable Social Security benefits (line 20a minus line 20b on the 1040)
  • Tax-exempt interest (line 8b on the 1040)
  • Exclude (line 45 and 50 from IRS form 2555)

With these figures in hand, you can calculate your MAGI and determine whether it falls beneath the FPL threshold prescribed by a particular federal, state, or privately funded program.

Simply multiply your MAGI by the prescribed threshold (e.g., less than 300 percent of FPL) to see if you qualify.

The federal poverty level (FPL), meanwhile, is a measure issued by the U.S. Department of Health and Human Services (DHHS) to determine whether an individual or family is eligible for federal assistance programs like Medicaid. In 2016, the DHHS set the following FPL guidelines for individuals and families:

  • $11,880 for individuals
  • $16,020 for a family of 2
  • $20,160 for a family of 3
  • $24,300 for a family of 4
  • $28,440 for a family of 5
  • $32,580 for a family of 6
  • $36,730 for a family of 7
  • $40,890 for a family of 8

    (The FPL for both Alaska and Hawaii are slightly higher.)

    Using these guidelines, a person whose MAGI is less than 138 percent of FPL would be eligible for Medicaid based on income alone. Similarly, assistance may be available to this whose MAGI is as low as 200 percent or as high as 500 percent of FPL. It’s a considerable span that can render benefits to even higher income families living with HIV.

    How high you ask?

    In hard dollar terms, a self-employed couple in Massachusetts filing jointly with an annual gross income of $90,000 and private health insurance could potentially have a MAGI of roughly $76,000. In Massachusetts, access to the state-run HIV Drug Assistance Program (HDAP) is open to couples with a MAGI of less than 500 percent of FPL (or $80,100 in 2016). Within these calculations, this couple would be eligible HDAP.

    By contrast, the same couple would not be eligible in Texas insofar as the state eligibility threshold is set at 200 percent of FPL (or $32.040 in 2016). However, a number of privately funded programs (see below) may be available those in higher income brackets.

    2. Take a Strategic Approach When Choosing an Insurance Plan

    Working out which policy is best for you and your family is often like putting together an ill-fitting puzzle. If you’re a person living with HIV, you would typically calculate your annual premium plus your annual deductible plus your annual drug co-pay costs to estimate your overall healthcare expenditure. A simple enough equation, it would seem.

    Or is it?

    Given the high cost of HIV drugs, it’s not unusual to find yourself paying more-or-less the same monthly costs irrespective of whether you get a high premium/low deductible/low co-pay policy or a low premium/high deductible/high co-pay policy.

    This is because HIV drugs will almost invariably be placed on a high-priced "specialty" drug tier if you have a low-cost policy. And, even if it’s not, your annual deductible will most likely be set so high that you’ll end up spending a fortune before you can even access any benefits.

    But it’s not always the case. Here a few, simple tips for choosing the right insurance policy if you are a person living with HIV:

    • Don’t avoid high drug coinsurance policies. Oftentimes we are so fixated on minimizing medication costs that we automatically omit policies that have drug coinsurance rates of anywhere from 20 percent to 50 percent. And that could be a mistake. Instead, remember to always look for the out-of-pocket maximum listed on a policy. In some cases, the ceiling could be set so low (e.g., $2,000 family/$1,000 individual) that you’ll reach your annual out-of-pocket limit within a month or two of starting. After that point, 100 percent of all healthcare costs would be covered by your insurance company, including all drugs, lab tests, doctor visits, and even inpatient services.
       
    • Check to see if there’s a drugs deductible. While most of us understand what a deductible is, some may not be aware that are sometimes two deductibles in a single policy: one specifically for prescription drugs and another for all other medical expenses. In such cases, the drugs deductible will invariably a fraction of the overall deductible, meaning that you can access your full drugs benefits far earlier than with a single deductible product. This is especially helpful if your HIV medications are listed on lower-priced drug tiers.
       
    • Check the drug formulary for potential savings. Drug formularies are issued each year by insurance companies to determine which tier a specific drug falls under. And it can vary significantly from insurer to the next. In some cases, a combination pill may be listed on a higher tier, while its component drugs are listed on a far less costly tier. This can afford you savings if the two drugs, for example, cost less than the single pill option—particularly if the combination drug requires coinsurance and the single pills only require co-payment. In almost all cases, co-pay is the cheaper option when it comes to HIV drug costs.
       
    • Consider private insurance over employer-based coverage. Common wisdom would dictate that employer-based ("group") health insurance is always the better choice, what with company subsidies significantly undercutting monthly premiums. And while it’s true that the average employee premium on a group plan is 143 percent less than that of an individual plan, lower premium costs often translate to higher overall spending, particularly for people living with HIV. Do the math before committing to any policy and consider opting out if a group plan doesn’t address your individual needs and budget.

    3. Make Best Use of ADAP Benefits

    The AIDS Drug Assistance Program (ADAP) has long been considered the first-line resource for HIV medications for low- to middle -income Americans. Since its inception in 1987, the scope of the program has expanded considerably, with some states now integrating medical care, lab tests, insurance assistance, and even HIV preventive therapy into their benefits schedule.

    As with other federally funded programs, eligibility is based largely on income, the thresholds of which can vary considerably from state to state. Proof of residency and documentation of HIV status are required.

    While most states will limit eligibility to U.S. citizens and documented residents only, some like Massachusetts and New Mexico have now extended ADAP assistance to undocumented immigrants, as well.

    Meanwhile, six U.S. states restrict benefits to individuals or families who personal net assets fall beneath a specific threshold, ranging from less than $25,000 in New York State to less than $4,500 in Georgia.

    The current ADAP income eligibility thresholds are outlined as follows:

    • Less than 200% of FPL: Arkansas, Iowa, Nebraska, Oklahoma, Puerto Rico, Texas
    • Less than 250% of FPL: Alabama
    • Less than 300% of FPL: Georgia, Illinois, Indiana, Kansas, Louisiana, Missouri, Mississippi, North Carolina, Ohio, South Carolina, South Dakota, Wisconsin
    • Less than 400% of FPL: Alaska, Arizona, Colorado, Connecticut, Florida, Hawaii, Minnesota, Nevada, New Hampshire, North Dakota, Rhode Island, Tennessee, Virginia, Washington, West Virginia
    • Less than 431% of FPL: Montana
    • Less than 435% of FPL: New York
    • Less than 450% of FPL: Michigan
    • Less than 500% of FPL: California, District of Columbia, Kentucky, Maine, Maryland, Massachusetts, New Jersey, Oregon, Pennsylvania, Vermont
    • Based on annual income: Delaware (less than $50,000), Wisconsin (varies by county)

    ADAP is typically considered a payer of last resort, meaning that, unless you qualify for Medicaid or Medicare, you will need to enroll in some form of private or employer-based insurance. (A handful of states do offer subsidized coverage for those who those unable to pay and/or are ineligible for Medicaid.)

    Before committing yourself to any insurance product, contact your state’s ADAP provider to see if you qualify for assistance. Based on the types of benefits you’re able to access, you can then select the insurance coverage appropriate to your individual need.

    If, for example, the cost of medications is your highest expense and you don’t foresee any other major annual health expenditure, you may be able to opt for an insurance product with a low monthly premium and a higher deductible and out-of-pocket maximum. In this way, you may only need to pay for your twice-yearly blood tests and doctor visits, nothing else.

    On the other hand, if you have other co-existing conditions or foresee high medical expenses for the year, you may need a policy that offers a lower deductible or out-of-pocket maximum. In this case, ADAP can significantly offset the high cost of treatment and may even, in some cases, provide access to medications used to treat HIV-associated illnesses.

    The bottom is this: work with your ADAP representative and provide him or her as much detail about both your policy benefits and current drug therapy. In this way, you can make a fully informed decision that addresses your individual budget and personal healthcare needs.

    4. Take Full Advantage of Manufacturer Drug Assistance

    When it comes to reducing the out-of-pocket expense of HIV drugs, we tend to focus almost entirely on federal/state programs and forget that assistance is readily available through virtually every major HIV drug manufacturer. These are typically offered as either insurance co-payment assistance or fully funded patient assistance programs (PAPs).

    HIV co-pay assistance (co-pay) is available to privately insured individuals and offer savings of anywhere from $200 per month to unlimited assistance after the first $5 co-payment (as with the drugs Edurant, Intelence, and Prezista).

    The application process is simple, and there are usually no restrictions based on income. This can be of significant advantage to those shopping for new insurance, allowing them to choose lower cost products in which either their drug co-pay or coinsurance costs fall beneath the prescribed annual/monthly benefit.

    Let’s say, for example, that you’re on the drug Triumeq, for which the manufacturer offers an annual co-pay benefit of $6,000 per year. If Triumeq is placed on a drug tier that requires co-payment, generally that benefit is ample enough to cover all co-pay costs.

    But, on the other hand, what can you do if Triumeq falls within a tier that requires 20 percent, 30 percent, or 50 percent coinsurance? In such case, you may able to find a policy with a low out-of-pocket maximum. You can then utilize co-pay assistance to cover all drug costs up until such time as you reach your annual maximum, after which all costs—drugs, X-rays, doctor visits—are covered 100 percent by your insurer.

    Another option is the HIV patient assistance programs (PAPs). PAPs were designed to provide free medications to uninsured individuals who are not qualified for Medicaid, Medicare, or ADAP. Eligibility is usually restricted to person or families whose previous year’s income was 500 percent below FPL (although exceptions can be made on a case-by-case basis for Medicare Part D clients or underinsured individuals whose healthcare costs have become unaffordable). 

    PAPs can often be lifesavers for people living in states like Texas, where Medicaid and ADAP are restricted to only the lowest income residents (i.e., 200 percent below FPL). Today, most PAPs are available to those living 500 percent below FPL, without any restrictions based on net worth.

    Moreover, if changes in state eligibility suddenly disqualify you for ADAP, you may still be able to qualify for PAP assistance even if you fall outside of the prescribed income threshold. By and large, PAPs are far easier to deal with when lodging an appeal compared to state offices, and can often direct you to other non-government programs that offer HIV-specific assistance.

    And One Final Thought

    While affordability is key to treatment success, never allow price alone to dictate treatment choice. While you may be able to save a few dollar by foregoing a one-pill option (e.g., Atripla) for the individual drug components (Sustiva + Truvada), such a change should be never made without the direct consultation with your treating doctor.

    This is especially true if you decide to change to a regimen for which any drug component is different from the ones you are currently on. Unmotivated change of therapy can increase the risk of premature drug resistance, resulting in early treatment failure.

    The bottom line is this: it is better to fully explore all avenues for assistance before considering any change of therapy that can potentially undermine your health. For more information, contact the not-for-profit Partnership for Prescription Assistance (PPA), which connects patients to assistance programs free of charge, or HarborPath, a non-profit group based in Charlotte, North Carolina that ships free HIV drugs to qualified, uninsured individuals.

    Sources:

    Farnham, P.; Gopalappa, C.; Sansom, S..; et al. "Updates of Lifetime Cost of Care and Quality-of-Life Estimates for HIV-Infected Persons in the United States: Late Versus Early Diagnosis and Entry Into Care." Journal of Acquired Immune Deficiency Syndromes. October 2003; 64:183-189.

    Kaiser Family Foundation (KFF). "Average Single Premium per Enrolled Employee For Employee-Based Health Insurance - 2015." Oakland, California; accessed December 8, 2016.

    KFF. "Average Monthly Premiums Per Person in the Individual Market." 2013; accessed December 8, 2016. 

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