Author: Qualify Health

Qualifying for free medication for expensive oral or infusion drugs is easier than most expect. In this article, we explore the eligibility requirements for PAPs and how QCSS can manage the entire process.

What is a Patient Assistance Program?

Patient Assistance Programs or PAPs are programs created by pharmaceutical manufacturers to help financially needy patients purchase necessary medications. The pharmaceutical company sponsors the program, and they help ensure that patients with low-to-moderate incomes, who are uninsured and underinsured, receive their medication at no cost. Each program is different, but they all require that the patient meet specific income guidelines.

Most patients are partially shielded from the high cost of medications through employer health insurance plans, Medicaid, or Medicare. Unfortunately, coverage gaps and formulary restrictions can financially burden even those with insurance. Uninsured patients or those without adequate prescription drug coverage will often pay for their medications out of pocket or not buy their medications due to a burdensome cost. Many are unaware of how PAP programs can help them receive their prescription without compiling vast amounts of medical debt in the process.

How to Qualify for PAP Programs

Eligibility and application requirements vary from program to program, which can sometimes make applying complex or confusing.

In general, you must meet the following requirements:

1. Be a permanent, legal resident of the United States or Puerto Rico
2. Prove you are uninsured or that your insurance does not cover your medication.
3. Meet specific income eligibility requirements

What are the Income Requirements for PAP Programs?

Most PAP programs require the patient to fall within a specific Federal Poverty Level (FLP) to qualify for free medication. FPL is an income threshold that varies by family size. FPL outlines the estimated minimum income required for a household to buy food, clothing, and shelter. The requirements differ for each PAP manufacturer but generally range from 300%-600%. See the chart below:

As you can see, the income requirements for PAPs are incredibly reasonable and allow many patients to receive the financial assistance they need when paying for expensive medications

How to Apply to the PAP Programs?

The application process is extensive. The programs generally allow you to apply over the phone or online. They require the patient to submit proof of income and residency to prove eligibility – they will request a copy of the previous years’ taxes or employer paystubs. Additionally, the program requires your physician to complete and sign a form to finalize the application. Once the application and the requested documents are submitted, it can take between 7-10 business days to receive approval or denial. Following up with the program is key to a successful application process.

How Q Consulting Support Services Can Help

The eligibility and application process can be complicated and confusing for patients. Q Consulting Support Services (QCSS) can step in and relieve the burden from the patient and the provider’s office. We will facilitate and manage the entire PAP application process through approval and scheduling delivery of the medication. QCSS has an excellent team ready to alleviate your facility from this burden to ensure your patients receive the medicine they need.

A breakdown of copay accumulators and copay maximizers for oncology practices to help patients better understand their insurance benefits.

What is a Copay Accumulator and Copay Maximizer?

A copay accumulator, also known as a copay maximizer, is a way of ensuring that the patient does not get out of their cost-sharing responsibilities with specialty medications. Insurance cost-sharing can be understood in the forms of copays, co-insurance, deductibles, and out-of-pocket maximums. Specialty medications and therapies are associated with a high risk of the patient experiencing financial toxicity for two reasons:

1. Specialty medications are vastly more expensive than traditional therapies.
2. Most chronic illnesses, such as cancer, are treated with these expensive specialty medications over a period that can span many years.

Manufacturer Copay Programs

Pharmaceutical manufacturers recognize that the therapies they make are expensive and lifesaving and have programs in place to help patient’s who are prescribed these medications with their out-of-pocket costs. These savings programs might include copay programs, free-trial offers, and Patient Assistance Programs (free-drug) depending on patient income level.

A good example of how these programs work is an oncology patient with commercial insurance, who are able to use copay savings programs to help make ends meet and get the treatment needed without an enormous financial burden. Copay savings programs will help the patient by covering their out of out-of-pocket cost thereby reducing their responsibility to as little as $0.

How Copay Accumulator’s Work

Manufacturers have copay programs in place in order to help patients drive down cost, and increase specialty medications access. However, the copay accumulator removes the ability to count these ‘outside payments’ towards their personal responsibility as it relates to their deductible and out-of-pocket maximum. This can be highly problematic for oncology practices and their patients who require long-term use of specialty therapies for four reasons:

1. Cancer patients have the highest treatment-related financial burden.
2. Cancer diagnosis and treatment directly impact patient productivity and ability to work.
3. Cancer patient suffering with financial toxicity have lower rates of treatment adherence and increased prescription abandonment due to high costs
4. Securing patient financial advocacy is time-consuming and challenging to find, causing an increased administrative burden on practice staff.

Best Practice for Oncology Practices

The best practice for oncology practices to help address copay accumulator and copay maximizer is patient education. Many health insurance companies roll out these new features to the prescription benefit plan without the patient’s knowledge. Understanding health insurance can be daunting to patients, so it is important to familiarize them with terms such as copay accumulator, copay maximizer, co-insurance, cost-sharing, and out-of-pocket costs. Encourage patients to become as knowledgeable as possible about their coverage, benefits, and cost-sharing responsibility.

Learn how Q Consulting Support Services can help your practice, by helping your patients.