Amy is back with the final installment of her miniseries Coverage Tips for Costly Drugs. Today she is going to take you through the alternative cost assistance programs, which may apply to different populations. It’s important to note that what is discussed below may not apply to you depending on your coverage situation. It is also important to note that different states have different policies in place, which may affirm or negate the topics discussed. This blog series is intended to get you thinking about payment strategies, but not necessarily describe the one that will work the best. It is up to you to evaluate different options, wherein the responsibility of what coverage solution you pursue rests solely on your shoulders. This blog series should not represent your sole source for determining healthcare coverage.

Welcome to the 3rd and final installment of the Coverage Tips for Costly Drugs series. Thus far, we have taken a deep dive in to private insurance and Medicare, offering a variety of tips to help keep your out of pocket costs down.

To tie this topic up in a neat bow, let’s examine accumulator adjustment programs as well as third party assistance programs – topics you’ll likely want to be well versed in moving forward.

It’s worth repeating: what follows are suggestions only. The health insurance landscape, Medicare, Medicaid, drug company support programs, and independent nonprofits that offer assistance can change at any time. What follows is broad commentary and may or may not necessarily apply to your specific case.

Accumulator Adjustment / Co-pay Accumulator Program

There are many articles out there about accumulator adjustment programs, including a blog Gunnar recently wrote, so I won’t reinvent the wheel here. Essentially, private insurance companies are stating that they aren’t going to allow drug manufacturer assistance program money provided to the patient to count towards a patient’s deductible or OOP max for the year. That’s obviously a bummer for the reasons outlined in the first post of this series; however, I’m not convinced that there isn’t a work around.

Often, manufacturer assistance programs are applied when a drug is adjudicated at the pharmacy – essentially the patient’s private insurance is billed for the medication first, and whatever is left over is billed to the manufacturer’s assistance program, then leaving a significantly smaller co-pay, if any at all, for the patient.

Drug manufacturers will also often allow you to use their assistance programs another way, too – you pay for your portion of the drug cost at the pharmacy out of pocket, and then you submit the paid receipt to the manufacturer. The manufacturer will then cut you a check for the difference between what you paid without the co-pay program and what you should have paid with it – like a mail in rebate. Be warned that in this case, out of pocket costs can initially be steep, especially if you’re dealing with a costly brand name drug, so it’s important to make contact with the drug manufacturer not only to make sure this avenue is open, but also to make sure you are eligible before making a large out of pocket payment. I’m not sure how the insurance company would know about this occurring because it’s a transaction exclusively between the patient and the drug manufacturer through the mail. If you are a victim of a co-pay accumulator adjustment program, it could be worth discussing this sort of reimbursement with a drug manufacturer to hit your deductible just like you would with a co-pay card.

Other related tips include:

  • Check to see if your state allows co-pay accumulator adjustment programs– some states have outlawed the practice
  • Check to see if your private insurance plan currently uses co-pay accumulator adjustment programs. If you get your private insurance through an employer, make sure to talk the employer about this policy. They may have accidentally signed up for the insurance plan under the impression it was a cost savings strategy. In reality, it’s anything but that.  You can also read your insurance plan contract where it will explain that manufacturer assistance programs (co-pay cards, etc.) won’t apply to the insured OOP max or deductible
  • Make sure you know the different names of this program that your insurance company may be using. Names can include “Co-pay accumulator,”  “Out of Pocket Protection Program,” “Specialty Co-pay Card Program,” “Coupon Adjustment: Benefit Plan Protection Program”
  • Check with the drug manufacturer to see if you can pay your co-pay upfront and then submit a reimbursement claim (side stepping insurance company – they will see that you paid full co-pay out of pocket cost, thereby applying it to your deductible and OOP max tally, but still reducing your OOP cost)

3rd Party Assistance Programs

HealthWell Foundation

The HealthWell Foundation’s assistance program can be used if you have Medicare or private insurance. As of today, HealthWell will give a person with CF up to $15,000 annually to assist with OOP costs – but I’m not sure they’ll have $15,000 for all of the demand from CFer’s that will grow quite a bit in 2020 with the approval of elexacaftor.

The HealthWell Foundation can run out of funding, so it’s a good idea to apply as soon as you know you will need assistance. And on that note, if you have been awarded a grant and know you won’t use a portion of your grant, please let HealthWell know so those funds can go to help another CFer in need. Quite a bit of money is awarded and not used in CF on an annual basis – meaning the funds are tied up and can’t be used by other people in financial need.

It’s important to note that HealthWell does have income guidelines.

Here is the LINK to apply for financial assistance.

The Assistance Fund

Like HealthWell, The Assistance Fund (TAF) can be used if you have Medicare or private insurance. Unfortunately, TAF isn’t as transparent about their income qualifications – income and household size are evaluated on a case by case basis once you apply for program assistance.

An application for The Assistance Fund can be found here.

This concludes the 3 part series on Coverage Tips for Costly Drugs. It’s my hope that you found it helpful and you are better equipped to strategize your insurance plan for 2020. I know insurance can be daunting, but it’s important to keep in mind that it’s do-able.

Questions? Reach out to Gunnar and he will get you in touch with me.  

The views expressed on any guest column [Coverage Tips for Costly Drugs], are that of guest contributors, and not necessarily those of Gunnar Esiason or the Boomer Esiason Foundation. Nothing in these blogs/articles should be considered medical or financial advice; such advice can only be given by a physician or certified professional who is experienced with cystic fibrosis, healthcare coverage or state and federal laws. The Boomer Esiason Foundation, Gunnar Esiason, and guests cannot be held responsible for any damage which may result from using the information on this website.