Patient Assistance Programs from Drug Companies: Eligibility Criteria Explained
Feb, 22 2026
Getting life-saving medication shouldn’t mean choosing between rent and refills. But for millions of Americans, high drug prices make that choice real. That’s where patient assistance programs (PAPs) come in - free or deeply discounted medicines offered directly by drug companies to people who can’t afford them. But here’s the catch: eligibility isn’t simple. It’s full of hidden rules, income limits, insurance traps, and paperwork nightmares. If you’re struggling to pay for prescriptions, this isn’t just helpful - it’s essential reading.
Who Actually Qualifies?
The biggest myth about these programs is that they’re for the completely uninsured. That’s only partly true. Most major drug companies - Pfizer, Merck, AbbVie, GSK, Takeda - require you to be either uninsured or underinsured. But what does "underinsured" really mean? It means your insurance doesn’t cover the drug you need, or your out-of-pocket costs are so high they push you into financial hardship. You can’t just have any insurance and still qualify. For example, Pfizer’s program outright denies people with commercial insurance, even if their plan doesn’t cover the medication. The same goes for GSK and AbbVie. If your insurer tells you to apply to the drug company’s program to get your drug, you’re already disqualified.Income Is the Gatekeeper
Nearly every program uses income as the main filter. The standard? A percentage of the Federal Poverty Level (FPL). For 2023, 500% of FPL means $75,000 a year for a single person, and $153,000 for a family of four. That sounds high - until you realize most programs don’t let you go that high. Pfizer’s program for routine medications like Eucrisa caps eligibility at 300% FPL - $43,200 for one person. For cancer drugs? They bump it up to 500-600% FPL. GSK uses $58,650 for one person and $120,570 for four. Merck allows hardship exceptions for insured people, but only if income is below 400% FPL and you can prove medical and financial distress.Here’s what trips people up: they report gross income, but programs use Modified Adjusted Gross Income (MAGI). That’s the number the IRS uses for Obamacare subsidies - it’s not your paycheck total. It’s your income minus certain deductions. If you file taxes, use your Form 1040. If you don’t, you’ll need pay stubs, W-2s, or a signed letter from your employer. One study found 31% of applicants messed up this step. Don’t be one of them.
The Medicare Trap
If you’re on Medicare, things get even trickier. Most drug company programs won’t help you if you’re enrolled in Medicare Part D - unless you’re below 150% FPL ($20,385 for one person in 2023). Even then, you must first apply for Medicare’s Extra Help program and get denied. Only then can you qualify for the manufacturer’s PAP. Why? Because Medicare doesn’t want drug companies subsidizing costs that should count toward your catastrophic coverage limit. If a PAP pays for your drug, that payment doesn’t count toward your $8,000 out-of-pocket threshold (2024 level). That means you stay stuck in the "donut hole" longer. Some people with income between $18,000 and $20,000 fall into a gap: too rich for Extra Help, too poor for PAPs. That’s real. That’s why 42% of applicants had to apply three or more times just to get approved.
Insurance Isn’t the Only Barrier
You need more than income. You need proof you live in the U.S. and are treated by a U.S.-licensed doctor. No exceptions. No international patients. No telehealth from abroad. You also need your doctor to sign off - not just a prescription, but a form verifying your diagnosis, treatment plan, and that you can’t afford the drug. This step alone delays approvals by an average of 28 days. And don’t forget: you’ll need to reapply. Every year for basic meds. Every three months for expensive cancer or autoimmune drugs. GSK requires annual re-enrollment. Pfizer asks for quarterly updates on specialty drugs. If you miss a deadline, your medication stops.What Drugs Are Covered?
Not all drugs are created equal. PAPs focus on high-cost medications - the kind that cost $10,000 a year or more. Oncology drugs? Almost always covered. Insulin? Yes. Rheumatoid arthritis biologics? Yes. Antibiotics? No. Blood pressure pills? Rarely. The median annual cost of a drug covered by a PAP is $1,157. For drugs not covered? Just $367. That tells you everything: these programs exist to help with specialty drugs, not generics. If your drug is cheaper than $500 a year, you probably won’t qualify. The programs aren’t designed for that.How to Apply - And Avoid Rejection
Here’s the reality: 37% of initial applications get denied. The top reason? Incomplete paperwork. Here’s how to avoid it:- Go to the drug company’s official PAP website. Don’t trust third-party sites.
- Use their online portal. Pfizer’s RxPathways, GSK’s Patient Assistance Foundation, Merck’s program - all have web forms now.
- Have these ready: Social Security number, proof of income (tax return, pay stubs, employer letter), proof of address, doctor’s contact info, prescription details.
- Double-check household size. 52% of errors happen here. Include everyone living with you who contributes to or depends on your income.
- Get your doctor to sign the form early. Call them. Don’t wait for them to call you.
- Apply for Extra Help first if you’re on Medicare. Save the denial letter.
AbbVie’s user testing showed the average application takes 27 minutes. Most errors happen in the income section. Use the IRS MAGI calculator if you’re unsure. And if you’re denied, don’t give up. Appeals are common. Many people get approved on the second try.
What If You Don’t Qualify?
If you’re turned down by the drug company, look elsewhere. Independent charities like the PAN Foundation and HealthWell Foundation sometimes help people who don’t qualify for manufacturer programs. They have stricter income caps (usually 400-500% FPL) but are more flexible on insurance. They don’t care if your plan tells you to apply to the manufacturer - they’ll help anyway. They cover over 60% of all charity PAPs now. You can also check with local clinics, pharmacies, or nonprofit groups like the Patient Advocate Foundation. They have navigators who can help you fill out forms and appeal denials.The Bigger Picture
These programs exist because drug prices are unsustainable. In 2021, pharmaceutical companies gave away over $20 billion in free meds. That’s a lot - but it’s still only 2.3% of total U.S. drug spending. Critics say PAPs let companies avoid lowering prices. They’re right. As long as patients can get help through these programs, there’s little pressure to cut costs. But for now, they’re the only safety net for millions. The Inflation Reduction Act will cap Medicare out-of-pocket costs at $2,000 in 2025. That could cut PAP use among seniors by 40%. But for the 27.5 million underinsured Americans - people with high deductibles, no coverage for certain drugs, or jobs without insurance - PAPs will still be a lifeline.Can I get help if I have private insurance?
Usually not. Most drug company programs require you to be uninsured or have insurance that doesn’t cover your specific medication. If your insurer tells you to apply to the manufacturer’s program, you’re automatically ineligible. Some exceptions exist for hardship cases under Merck’s program, but you must prove extreme financial and medical need.
Do I need to be a U.S. citizen to qualify?
No. Citizenship isn’t required. But you must live in the United States and receive treatment from a U.S.-licensed doctor. Proof of U.S. address - like a utility bill or lease agreement - is mandatory. Programs won’t help people living abroad, even if they’re U.S. citizens.
How long does it take to get approved?
Approval usually takes 7 to 14 days. Once approved, most people receive their medication within 72 hours. Delays happen when paperwork is incomplete. Doctor signatures, income documents, and Medicare denial letters are the most common holdups. Applying early and double-checking every form can cut processing time in half.
Can I apply for multiple drug assistance programs at once?
Yes. If you take several expensive medications, apply for each program separately. Many people get help for insulin from one company, cancer drugs from another, and autoimmune meds from a third. There’s no rule against applying to multiple programs. Just make sure you meet each one’s specific eligibility rules.
What if my income changes after I’m approved?
You must report it. Most programs require you to re-verify income every year - or every three months for specialty drugs. If your income goes above the limit, your aid may stop. If it drops lower, you might qualify for more help. Don’t wait. Contact the program immediately. Most have dedicated phone lines or online portals to update your status.
Are PAPs the same as coupons or discount cards?
No. Coupons and discount cards (like GoodRx) are for people with insurance and only reduce your copay. They don’t cover the full cost. PAPs give you the medication for free or at a very low cost. You can’t use coupons if you’re on Medicare Part D - but you can use PAPs if you meet the income rules. They’re completely different systems.