Insurance and Co-Pay Assistance
Last Modified: July 15, 2016
Know the terms and your coverage!
Contact your insurance company PRIOR to starting treatment to investigate the following:
- This is the amount you pay for health care services before your health insurance begins to pay.
- Some co-pay foundations MAY cover all or part of your deductible.
- This is your share of the costs of a health care service.
- It is typically figured as a percentage of the total charge for the service.
- You are responsible to pay coinsurance plus any deductibles you still owe.
- Co-pay foundations typically cover out of pocket co-insurance charges for approved treatments for patients that meet their eligibility criteria (more below).
- Some insurance plans have an annual maximum out of pocket. Once your reach this, services are typically covered at 100%.
- This is a fixed amount you pay for a health care service, typically paid when you receive the service.
- The amount can vary by the type of service.
- You may also have a co-pay when you get a prescription filled.
- Co-pays for prescriptions are typically covered by co-pay foundations
- Some co-pay assistance foundations will cover the cost of office visits co-pays ONLY IF the patient is receiving treatment on the same day.
What is co-pay assistance?
- Co-pay assistance is financial assistance for co-pays or co-insurance for patients WITH insurance who UNDERINSURED.
- Underinsuredmeans that the patient has out of pocket costs, which are not covered by the medical insurance plan, which can impact financial well-being and access to care.
What kind of assistance is available to help me pay for the cost of my treatment?
- Private co-pay assistance foundations provide assistance with co-pays and SOME out of pocket medical expenses. These foundations are funded by the pharmaceutical industry, as well as private donors.
- EACH foundation has specific diagnostic and financial criteria a patient must meet to be eligible for assistance.
- Co-pay assistance does not cover off label or experimental treatments.
- Some funds are available to assist with the payment of health insurance premiums or COBRA premiums.
- Patients CAN receive assistance from multiple foundations.
What organizations are available to help me with co-pay assistance?
- Cancer Care Co-Pay Foundation
- The Leukemia and Lymphoma Society Co-Pay Assistance Program
- Patient Advocate Foundation Co-Pay Relief Program
- The Chronic Disease Fund
- The Healthwell Foundation
- Patient Services Incorporated
- National Association for Rare Disoders (NORD)
- Patient Access Network Foundation
- Johnson and Johnson Patient Assistance Foundation
- The Assistance Fund
Important points about co-pay assistance:
- Patients must meet BOTH diagnostic and financial criteria to qualify for assistance.
- Each foundation has their own list of diseases that they cover.
- Each foundation has their own financial criteria for assistance.
- Co-pay assistance covers the costs of the medication (oral and IV).
- Co-pay assistance DOES NOT cover costs of nursing, pre-medications or administration of the medication.
- Co-pay assistance typically does not cover co-pays for diagnostic imaging, labs, or radiation.
- For programs that do cover office visit co-pays (LLS and Cancer Care), office visits can be covered under Co-Pay assistance ONLY if the patient is receiving chemotherapy on the SAME DAY.
- Co-pay assistance DOES NOT apply to the uninsured.
- Co-pay assistance (private foundations) differs from co-pay cards (drug company sponsored).
- Co-pay assistance DOES NOT apply to treatments that are DENIED by the insurance company.
- Co-pay assistance DOES NOT apply experimental, non-approved treatments.
What about co-pay cards?
- The co-pay card is a means by which pharmaceutical manufacturers offer instant rebates to patients.
- Like co-pay assistance, co-pay cards can assist when patients struggle with treatment adherence due to out of pocket cost for the medication at the commercial pharmacy.
- Co-pay cards are ONLY for patients who have private/commercial insurance.
- Patients with Medicare, Medicaid, or Tricare are NOT eligible for co-pay cards.
Who can help me apply for co-pay assistance?
- You can contact any of the foundations listed above directly to initiate an application.
- Your oncology social worker, navigator, or a financial counselor in your cancer treatment center should be able to help you with the process of determining what programs you may be eligible for as well as helping with applications and facilitating medical information getting to the foundation in a timely fashion.
- Don't forget, it is important to communicate with your cancer care team about how the costs of your care may be how impacting your ability to participate in your treatment plan.