Insurance and Co-Pay Assistance

Author: Christina Bach, MBE, LCSW, OSW-C
Last Reviewed: July 11, 2022

What is Co-Pay Assistance?

Co-pay assistance is financial assistance for co-pays or co-insurance for patients WITH insurance who UNDERINSURED.

  • Underinsuredmeans you have out-of-pocket costs, which are not covered by the medical insurance plan.

What kind of assistance is available to help me pay for the cost of my treatment?

  • 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?

What You Need to Know

  • You must meet BOTH diagnostic and financial criteria to qualify for assistance.
    • Each foundation has its own list of diseases that they cover.
    • Each foundation has its own financial criteria for assistance.
    • Financial criteria can also vary based on the disease covered by a particular fund.
  • Co-pay assistance covers the costs of the medication (oral and IV).
    • Co-pay assistance DOES NOT cover the costs of nursing, pre-medications, or administration of the medication.
  • Co-pay assistance (except funds through the LLS) 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 treatment on the SAME DAY.
  • Uninsured individuals are not eligible for co-pay assistance.
  • 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.
  • Some co-pay assistance foundations may also offer assistance with health insurance or COBRA premiums.

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 costs 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.

Related Blog Posts

October 13, 2023

3…2…1…Countdown to Medicare Open Enrollment

by Christina Bach, MSW, LCSW, OSW-C

September 1, 2023

Coming Soon: Medicare Drug Price Negotiations

by Christina Bach, MSW, LCSW, OSW-C

August 18, 2022

10 Ways the Inflation Reduction Act will Impact Cancer Care

by Christina Bach, MSW, LCSW, OSW-C