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Paying for Prescription Formula: “Thinking Outside the Can” part 3

Question: 

Paying for Prescription Formula: Thinking Outside the Can  is a three-part series of articles providing information regarding financial assistance for enteral formula, dietary supplements, prescription Medical Food, and the durable medical equipment and other supplies necessary to administer enteral feeds.  This article focuses on a program that provides low- and no-cost formula and supplements to uninsured and under-insured individuals, especially individuals who receive Medicare benefits.  Part 1 provides information for enteral nutrition users of all ages, and  information for adults are addressed in Part 2.   

Answer: 

Medicare recipients in need of supplemental enteral nutrition must pay out-of-pocket if taken by mouth, even if the formula is medically necessary and constitutes 100% of the individual’s oral intake.  These same products are approved for 100% Medicare coverage if administered through a permanently-placed feeding tube, such as a PEG tube.  Enteral nutrition can be very expensive, and many disabled individuals simply cannot afford special formulas, which may cost several hundreds to thousands of dollars per month.

The Prescription Hope program provides very low cost medication and medically-necessary nutritional supplements/enteral feeds to individuals who are uninsured or under-insured.   Many individuals who are uninsured, have very high deductibles and copays, or receive Medicaid but are not yet eligible to receive services (sometimes this wait-period is called “the Donut Hole.”) Initial enrollment into the program is a one-time fee of $20.  Each month’s supply of medication or medically necessary nutritional supplement costs $20, regardless of the wholesale cost of the medication or medical food. 

Many pharmaceutical companies offer programs that distribute necessary medication to individuals who cannot afford to purchase it.  Unfortunately, if a patient is on 12 different medications that are dispensed by 8 different drug plans, each with their own application, it is very easy for the patient to miss questions or make clerical errors, both of which can disqualify an applicant.  Prescription Hope acts as a pharmaceutical service coordinator, providing support from your initial phone call or email inquiry until the medication or formula arrives on your doorstep. Then the support continues as you renew your application, change to another type of formula or supplement, or no longer need/qualify for the support. 

Who is Eligible?

You may be eligible for this program if:

·         Your annual gross earnings are less than $30,000 for an individual living alone, or $50,000 or less for a family of two.   (NOTE: These are average figures; some pharmaceutical companies’ guidelines may be higher.)

·         You do not receive Medicaid benefits and you are not eligible for them.  

·         You are experiencing financial hardship.

·         You may receive federal Medicare benefits

·        You may have a discount prescription drug card (see example)

 

 

How Do I Apply?

The application can be found here:  http://www.prescriptionhope.com/pdf/PrescriptionHopeApplication.pdf

 

Before applying to Prescription Hope, you must be able to produce the following documentation:

·         Medicaid rejection letter   (Prescription Hope applicants must prove Medicaid ineligibility; in order to receive this documentation, you must apply to Medicaid in your home state. )

·         Written, signed statement explaining factors responsible for financial hardship.  Common reasons for financial hardship include:

o   Loss of employment income due to medical and non-medical resignation or layoff

o   Significant out-of-pocket medical expenses, such as medically necessary OTC meds

o   Higher than usual household expenses, such as high electric bills due to O2 concentrator, vents, CPAP/BiPAP, refrigerator specifically used for medical needs, charging electrically powered wheelchairs, enteral/parenteral pumps, etc.

o   Extended or frequent hospital admissions

o   Assistance Dog expenses

o   Current list of medication and supplements (*Note: If your physician has ordered a medically necessary medication that you cannot afford, mention this on your application.)

·         If you have a private HMO, make copies of the HMO policies regarding coverage of oral nutritional supplements and/or enteral nutrition taken by mouth, and temporary enteral feeding (NG/ NJ tubes). 

·         An original prescription and letter of medical necessity is required for all nutritional supplements and medical food, including products that are available without a prescription.

Which products are available through Prescription Hope?

Prescription Hope supports an extensive list of enteral supplements and complete nutrition:    Oral nutritional supplements


·         Enlive: Clear liquid carbohydrate and protein supplement; fat free

·         Hi-Cal Drink: Oral calorie supplement, 2cal/ml, served as a high-calorie alternative to milk or juice

·         Juven: powdered Arginine and Glutamine supplement: “JUVEN is a targeted therapeutic nutrition drink mix that has been clinically shown to support tissue repair,1 and to help build and maintain lean body mass (LBM).2”

·         Polycose: powdered Carbohydrate-based calorie supplement

·         ProSure   Powdered supplement that is high in calories and Omega-3 fatty acids; marketed to patients at risk of weight loss related to cancer

·         ProViMin Powdered Protein, Vitamin, Mineral, and Iron supplement.  Used with infants and children who require a modular formula due to metabolic disorders.

Nutritionally complete formula that can be taken by mouth or through an enteral feeding tube:

·         Ensure

·         Ensure Fiber with FOS

·         Ensure High Protein

·         Ensure High Calcium

·         Ensure Plus

·         Glucerna

·         Glucerna HiCal Shake

·         Glucerna Select

·         Jevity 1 Cal

·         Jevity 1.2 Cal

·         Jevity 1.5 Cal

·         Promote

·         Promote w/ Fiber

Formulas used with children less than 10 years of age

·         Elecare Jr.

·         PediaSure

·         PediaSure Enteral Formula

·         Vital Jr.

      Formulas used by individuals with specific metabolic disorders:

 


Cyclinex-1 powder; Cyclinex-2 Powder; Ketonex-1 Powder; Ketonex-2 Powder; Phenex-1 Powder; Phenex-2 Powder; Pro-Phree Powder; Propimex-1 Powder; Propimex-2 Powder; RCS (Ross Carbohydrate Free); Tyrex-1 Powder; Tyrex-2 Powder.

Formulas for individuals with metabolic stress or GI Malabsorption: Elemental, semi-elemental, MCT lipid blend:

·         Elecare; Osmolite 1 cal; Osmolite 1.2 cal; Osmolite 1.5 cal; Perative; Vital HN; Pivot 1.5 cal.

     Formulas used by individuals with specific primary illnesses

·         Nepro with Carb Steady (Chronic Renal Failure/Dialysis)

·         Oxepa (Patients with acute inflammatory response secondary to Sepsis, ARDS, and other Acute Catastrophic Illness)                  

·         Suplena with Carb Steady (End Stage Renal Disease)

A full list of prescription meds available via Project Hope can be found here: http://www.prescriptionhope.com/what-we-offer-full.html

 

©Copyright 2013 by Heidi Martin-Coleman and www.MitoAction.org.  Permission required to reproduce.  Contact information and content is accurate as of 2 July 2013, but is subject to change without notice. Resources provided by Coleman Connect are intended to support, not replace, recommendations from your health care provider.  Information provided on this site does not imply endorsement by MitoAction.org.  Please consult your health care provider before any change in treatment or nutrition.

This article was produced in conjunction with the Oley Foundation.  

 The information provided on this site is designed to support, not replace, the relationship between a consumer and his or her physician. All issues, ideas, suggestions etc. should be discussed with your health care provider prior to actual use.  Medical information is reviewed by clinicians in a relevant field, but does not imply endorsement by the Oley Foundation. If you have questions or suggestions please contact Oley's LifelineLetter Editor, Lisa Metzger, at metzgel@mail.amc.edu.