Guidance for When You Can’t Afford a Medication
The price of medicine remains a substantial barrier to access.
Even before the current COVID-19 crisis, the affordability of and access to medications was a significant issue worldwide. The World Health Organization estimates that two billion people globally still lack access to essential medications.(1) Whether you're in a low-, middle- or high-income country, the issue is the same –although it affects each country and region to different degrees. The price of medicine remains a substantial barrier to access.
In the United States, millions don't take their medications as prescribed – or even at all – due to cost. (2,3) This poses a considerable risk to their well-being, as these medications could save lives, prevent illness and suffering, and allow individuals a chance at living a better quality of life. We all may know someone who has struggled to obtain a medication they need. It truly affects us all.
Unfortunately, the number of individuals that are experiencing hardship is increasing. Millions have lost their jobs, many of whom have also lost health insurance as a result. The current COVID-19 crisis has amplified a patient's inability to afford medications. This issue isn't just applicable to those who don't have health insurance; even individuals with insurance are struggling with high copayments or out of pocket expenses. Many people also have less disposable income; so, the amount of money they can spend on medications may be less than before. For some, any out of pocket expense, in general, is significant.
Let's discuss how to begin to approach this issue on an individual patient and healthcare provider level – that is, let's start to answer the question of "What can a patient do when they can't afford a medication?"
This topic is broken down into two sections: advice for patients and advice for healthcare providers.
Advice for Patients
Patients, in this case, are any individual who needs or uses a medication(s). Ultimately, this is relevant to everyone at some point – as many of us may be taking medication now or may take one in the future.
Addressing patients
It's critical that you know that you should never feel embarrassed if you can't afford a particular medication. Multiple factors influence one's ability to afford medication. Also, medications are priced so differently. There have been cases where patients had no issues with paying for particular medications, but then they get prescribed a new medication that is very expensive or the price of the medication they were taking changes, and now they are unable to afford that medication. So, what to do?
Below are nine items to keep in mind as you work towards tackling this question.
1 - You are part of the decision-making process
You are part of the decision-making process, and it's vital that you make informed decisions. Therefore, you need to do your research. Learn by first understanding and seek out the resources available to you. This requires an organized approach on your part.
2 - You need to plan ahead
You need to plan ahead. The more you know regarding resources available to you, the more you can do given the situation.
3 - Identify your “partners” in this process and create a team of partners
Identify your "partners" in this process and create a team of partners. Now, who are your potential "partners," you may ask? Examples of partners include your healthcare providers (such as your physician and pharmacist), health insurance companies, pharmacies, and community or professional organizations advocating for your particular health condition. These partners can help identify strategies to lower prices (some may potentially replace the medication with a cheaper alternative), or they can help with finding resources on assistance programs. They may have information on where you can go or what is available to you to use. Professional organizations can also be a suitable partner. Contact professional organizations that focus on your specific health condition. For example, you have diabetes, visit the websites, and reach out to those organizations concentrating on diabetes. These types of organizations often have resources and can provide some insight into the latest programs and initiatives affecting individuals with that health condition.
4 - Keep lines of communication open
Keep lines of communication open. Do not feel uncomfortable telling your healthcare provider and other identified partners that you are having difficulty affording your medication. They are there to help. Their number one priority is to ensure you can take the medications you need to improve your health. Them knowing will only accelerate the process to assist you in obtaining the medication. For example, when you let your prescriber know that price may be an issue for you, the prescriber can anticipate a pharmacy call if you need the medication switched. Or they may need to fill out paperwork to communicate the need for this medication to your insurance for them to pay, or they may enroll you in an assistance program.
5 - Determine how and where you will get your medication
Determine how and where you will get your medication. The sources of the medications – or where you will get the medication – are essential to identify. Patients can access prescriptions through several medication sources that currently act as the patient's "pharmacy." Traditionally, the medication source is perceived to be a traditional community/retail or independent pharmacy. Other medication sources include outpatient hospital pharmacy services, pharmacies within community health clinics, physician's offices where drug samples and prescription medications are dispensed directly to patients, mail-order pharmacies, electronic pharmacies or internet pharmacies, and importation of prescription medications from other countries.
Different barriers exist for these various medication sources, and no medication source is free of barriers to access. Beware of using unregulated internet pharmacies that may have adulterated or falsified medications. Now back to the question: How will you obtain your medication? Will you go to the pharmacy? Will you have it delivered? Do you know how much it costs you beforehand? Have you had a conversation with the pharmacy team? Do you understand your options for receiving the medication, and what much will it cost you? Is there an added charge to using one particular method over another? Sometimes it's cheaper to go a specific route, so I'd recommend looking into that. It is essential to discuss this with your partners team. Now there are several access concerns given the current COVID-19 crisis – as you may not be able to go to the pharmacy to get the medication (or have had to limit your visits) and you have to or prefer to use other methods like delivery or mail order.
6 - Account for how much time things will take
Account for how much time things will take. Time is a critical factor to take into consideration. Things take time and may take longer than you have anticipated. Communication with providers can also take time. When you have multiple individuals working together (e.g., prescribers, an insurance company, pharmacies, in such a case), hearing back from people takes time. Taking the time to call several medication assistance programs or going through the assistance program application/enrollment process can be cumbersome to many patients. It can take a considerable amount of time, so make sure you have enough medications, so you don't go without any.
7 - Make sure you have the medication you need as soon as you need it
Make sure you have the medication you need as soon as you need it. If we're talking about an existing medication you take and need a refill on a medication, check the medication quantity on hand – that is, how much of the medication do you have? Don't go without medications and try to have enough until you have access to more. Evaluate whether you have or need a 30 versus 90 days. This is especially true if you're trying to reduce the number of visits to the pharmacy. If it's a new medication, consider talking to your healthcare providers to see if there is a known cheaper alternative (that is also clinically appropriate) that you can start as soon as possible.
The medication may not be available due to several reasons. The availability of the medication may impact the price. When medication is not available, work with your healthcare provider – both your pharmacist and prescriber – to find an alternative medication that will work for you. This is why it's imperative to call ahead and not wait until you're completely out of medication.
8 - Research and evaluate the resources available
Research and evaluate the resources available. There are several different assistance programs, and each has its pros and cons. Determine what you can qualify for and what is best for you. You may need to use a combination of resources depending on your situation.
Examples of resources include:
Medication assistance programs or patient assistance programs (PAPs) provided by pharmaceutical companies
Government and state drug assistance programs
Prescription insurance companies may have programs or initiatives run by its own entity – like lower copayments or free medications
Pharmacy programs can include medication programs available at local pharmacies to help reduce the cost of specific medications
Discount cards or coupons
Drug samples
Nonprofit assistance programs
Professional organizations assistance programs
What to do:
Check the name of the pharmaceutical company that makes your medication.
Visit the company or medication website. On the website, there may be a section that highlights assistance programs.
Do your research on other programs that are available to you. Do a basic internet search of resources in your area and resources available for the specific health condition or the medication itself. Compile the programs and go through and check the requirements. Now, different states (even on a local or institutional level) have different requirements for assistance programs and drug samples availability. For many programs, you may have to verify your financial situation or financial need. This is why it is vital to check each program's requirements.
Many of these assistance programs are not a sustainable, long-term solution. The eligibility criteria and process can regularly change, or they can abruptly stop the program altogether. Therefore, ensure you are frequently communicating with your healthcare provider and partner team.
9 - Watch out for any scams
Watch out for any scams – in terms of programs or medication sources (i.e., internet pharmacies). Make sure they are from trusted and regulated sources.
Advice for Healthcare Providers
Healthcare providers include prescribers (physicians, nurse practitioners, PA, dentists – anyone that can prescribe), nurses, and pharmacists.
Addressing healthcare providers
Building upon the nine items addressed to patients in the previous section (above), below are four items tailored to healthcare providers who are assisting patients to access their medications.
1 - Talk to your patients
Talk to your patients. Many patients won't be very straightforward and tell you right away that they are struggling to afford a medication. Merely stating a drug is "affordable" based on an index or guideline does not tell us whether the patient values that service or is willing to pay for the medication. What may seem "affordable" to you may not be affordable to the patient, so make sure to have an open conversation on this topic.
2 - You will be the patients leading partner and advocate
You will be the patients leading partner and advocate. You have the ability to assist a patient significantly. Familiarize yourself with the different types of assistance programs available for the medications you frequently prescribe or the ones that you know pose a significant burden on patients. I also recommend that you highlight the "advice for patients" items we discussed above to your patients during your conversations.
3 - Consider low-cost alternatives right away or when you can
Consider low-cost alternatives right away or when you can. Many of the assistance programs are for brand medications – but it's essential to keep in mind and ask yourself what will happen after these programs stop providing the medication to the patient. Will you switch them to less costly options? Are there generic options for the medication? Often generic medications are lower in price. Is there a reason you're not already prescribing the lower-cost alternative right away? You will know what is best clinically for the patient – and when alternatives are appropriate, but make sure to have a conversation about cost and affordability with patients.
4 - Talk to other partners that are working to ensure the patient received the medication
Talk to other partners that are working to ensure the patient receives the medication, such as the pharmacy team, insurance company, or assistance programs. Healthcare professionals should evaluate the available methods to increase access to medications for the population they are serving. Several patient and drug assistance program resources have been created to assist healthcare professionals in determining if an assistance program is available for the patient's needs. Depending on the requirements of the assistance program, you may be required to fill out paperwork and initiate the application process to verify the need. Most pharmaceutical companies require contact with prescribers before dispensing.
These strategies can't offer any guarantees for getting the medication needed at the price the patient can afford, but it may help provide more clarity on what resources are available to a patient and general approaches to take with the hopes of assisting in any way. You may need to utilize a combination of strategies or programs, various resources, and advice. You can't always rely on using just one approach. Please remember, the strategies suggested may not work in every situation or case. Things are continually changing; therefore, you have to do your research and investigate what options are out there for patients to utilize.
Overall Guidance
Regardless if you are a patient or healthcare provider, you need to determine two key things:
1. How long you need the medication
2. What are the short-term vs. long-term solutions to obtaining the required medication?
Some of the current resources out there are short-term solutions in that they won't provide an individual with a consistent supply of medication. If the patient needs to take a medication for an extended period of time, it is critical to partner with multiple individuals (the partner team identified earlier) to determine the best approach. This is especially true if the patient is taking chronic medications and will need a long-term solution. The rules and criteria for the assistance programs are continually changing; they take a long time and provide no guarantees. We continue to see changes in insurance policy reform, regulations, and price controls – all impacting the affordability and availability of medications.
Now, these recommendations or resources may be more relevant to those in the United States. If you're outside of the US, you are likely to have your country or region-specific assistance programs. But in general, the structure or how to approach the issue at hand is similar. For example, seeking out available resources (this maybe individual searches and discovery or in partnership with various individuals), improving communication, and working together with partners are needed, regardless of location. Again, these strategies can't provide any guarantees that a patient will be able to get the medication you need at the price you can afford, but it may help provide more clarity on what resources are available to a patient.
The affordability of medications will remain an ongoing critical issue that requires our attention. Our efforts today can have a positive impact on improving the affordability of medications for patients, now and into the future.
1. World Health Organization. Access to medicines: making market forces serve the poor. https://www.who.int/publications/10-year-review/medicines/en/.
2. Kaiser Health News. One In Five Americans Can’t Afford Prescriptions With Gender Gap Getting Increasingly Worse. Nov 2019. https://khn.org/morning-breakout/one-in-five-americans-cant-afford-prescriptions-with-gender-gap-getting-increasingly-worse/
3. Kaiser Family Foundation. Poll: Nearly 1 in 4 Americans Taking Prescription Drugs Say It’s Difficult to Afford Their Medicines, including Larger Shares Among Those with Health Issues, with Low Incomes and Nearing Medicare Age. Mar 2019. https://www.kff.org/health-costs/press-release/poll-nearly-1-in-4-americans-taking-prescription-drugs-say-its-difficult-to-afford-medicines-including-larger-shares-with-low-incomes/
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