Overview of Co-Pay Assistance and Financial Assistance Resources

Christina Bach, MBE, MSW, LCSW, OSW-C

Educational Content Specialist and Psychosocial Content Editor, OncoLink

christina.bach@uphs.upenn.edu

Fact: Cancer is expensive

• 68% of personal bankruptcies in the US are the result of medical debt.

• 78% of those declaring personal bankruptcy due to medical debt were INSURED (Woolhandler, et.al. American Journal of Medicine, 2009).

• One out of four cancer patients avoids filling prescriptions due to cost (The Oncologist, 2013).

• 42% of insured cancer patients express a significant or catastrophic financial burden (The Oncologist, 2013).

• 11 of the 12 cancer drugs approved by the FDA in 2012 cost over$100,000 per year.

Fact: Cancer is expensive

• 55% of cancer patients surveyed said the stress of dealing with costs negatively affects their ability to focus on their recovery (Association of Oncology Social Work).

• 36% of patients have discussed the cost of treatment with their oncologist (Association of Oncology Social Work).

• 16% of patients and caregivers report that they believe their oncologists give a lot of thought to the financial implications of the treatment they prescribe (Association of Oncology Social Work).

• About one half of patients surveyed feel comfortable speaking with health professionals about financial issues (Association of Oncology Social Work).

Insurance doesn’t cover everything:Do you know your potential costs?• The patient is ALWAYS responsible for

• Premium-what your plan costs every month

• Deductible-a fixed dollar amount you pay BEFORE your insurance pays anything

• Co-pays-a fixed cost sharing amount assigned to a specific service

• Co-insurance- usually a percentage: plan is responsible for “x” %; patient is responsible “y” %

• MOOP-maximum out of pocket the individual pays; usually assessed annually

Not to mention…

• Changes in work and income due to medical condition and treatment schedule

• Waiting periods for disability

• Cost of COBRA coverage if unable to work

• Non cancer related life needs---housing, transportation, food, utilities, phone

Why is increased access to copay/financial assistance important?• Improves access to care

• Improves adherence to treatment plan

• Improves patient outcomes

• Improves quality of life

Is there help out there?????

What is Co-Pay Assistance?

• Co-pay assistance is financial assistance for co-pays/co-insurances (patient responsibility) for patients WITH insurance—but whom we would consider to be UNDERINSURED (commercial/private/Medicare)

• Patients must meet BOTH diagnostic & financial criteria

• Co-pay assistance covers costs of medication (oral and IV); some co-pay foundations also cover insurance premiums as well as transportation/travel• But again, this is dependent on diagnostic criteria

What is Co-Pay Assistance

• Co-pay assistance typically does not cover co-pays for diagnostic imaging, labs, radiation, or office visits*• *unless treatments are administered on the same day as the office visit

• Co-pay assistance is not available to the uninsured

• Co-pay assistance differs from co-pay cards

• Co-pay assistance can not be applied to treatments that are DENIED by the insurance company or are experimental/off label uses of medications

Co-Pay Assistance Foundations

• Receive their funding from private donors and pharmaceutical companies

• Each foundation decides WHICH treatments are covered for each diagnosis by their co-pay assistance foundation (a formulary)

• Will cover both oral and IV medications as indicated on their formulary

Name Amount Eligibility Assistance covers

Leukemia and Lymphoma Society Copay Assistance Programwww.lls.org(877) 557-2672

$10000Renewable annually based on available funding

500% FPL • Disease related and approved treatments (oral/iv)

• MD office visit copays on same day as treatment

• Premium assistance

Patient Access Network Foundationhttps://www.panfoundation.org/866-316-PANF

$10000Renewable annually based on available funding

500%FPL • Disease related and approved treatments (oral/iv)

Patient Advocate Foundationhttp://www.copays.org/866-512-3861

$10000Renewable annually based on available funding

400% FPL • Disease related and approved treatments (oral/iv)

Name Amount Eligibility Assistance Covers

Cancer Care Co-Pay Assistance Foundationcancercarecopay.org866-552-6729

$7000Renewable annually based on available funding

400% FPL • Disease related and approved treatments (oral/iv)

Chronic Disease Fundhttp://www.cdfund.org(877) 968-7233

No set cap across the board; award is case by case and takes into account cost of living

Based on cost of living, outstanding medical bills and income

• Disease related and approved treatments (oral/iv)

• Some transportation and lodging costs (separate application process)

Co-Pay Cards• The co-pay card first appeared in 2005 as a means by which pharmaceutical

providers could offer instant ‘rebates’ or ‘discounts’ to patients.• This helps to combat some of the challenges to prescription pharmaceuticals,

including• Generic competition • Lack of patient adherence and persistence due to out of pocket cost for the medication at the

commercial pharmacy

• Co-pay cards are ONLY for patients who have employer based/private/commercial insurance.• They are not available to patients with Medicare Part D sponsored RX plans or

Medicaid• You are eligible to use a co-pay card if you have an ACA (aka “Obamacare”)sponsored

plan

• For eligible patients, these cards can be very helpful for privately insured patients receiving some high dollar drugs.

How do I apply?

• Gather necessary documents• Proof of income• Diagnosis and treatment information• Copies of insurance cards

• Identify and contact the fund/pharmaceutical company

• Be sure all documents are completed by your care provider ASAP

• Keep copies of your award letter and instructions on how to utilize funds

• Ask your care team for help!!!

I’m approved, now what?

• GET ORGANIZED!

• If you are using your award for oral medications, contact your pharmacy and provide them with information about your funding source• Most specialty pharmacies are very experienced with working with

copay assistance funds!

• For chemotherapy (IV) related bills, collect explanation of benefits (EOB’s) from the payer and bills from the provider.• You must have matched EOB’s and bills to submit a payment request• It is POSSIBLE to have the foundation billed directly by your treatment

site, but this is very dependent on your treatment site’s billing policies and processes

USE IT OR LOSE IT!

• Apply when you need funds

• If you don’t submit claims to the foundation within a set period of time (varies amongst each group) you will LOSE YOUR FUNDING

• With most funds, you cannot apply again if you lose your funding until a year has passed from the initial application

• Stay on top of submitted claims and keep records of payments received

Other sources of prescription assistance• Partnership for Prescription Assistance (PPA)

• Needymeds.org

• Rx Relief Pharmacy Discount Card

• RxAssist

• RxOutreach

• Xubex

• Generic Programs-Target, Wal-mart, Shoprite

• These programs do not often offer assistance for cancer drugs, but they do offer assistance for many medications used for symptom management (depression, anxiety, nausea, diarrhea, seizures) and can be accessed at significant savings

Other sources of prescription assistance• Medicare Part D Recipients: Low Income Subsidy- “Extra Help”

• PA-PACE/PACENET

• NJ-PAAD

Other sources of financial assistance• American Cancer Society (ACS)

• Cancer Care• Has a specific program for transportation reimbursement for Myeloma

patients

• Stomp the Monster

• Bringing Hope Home

• Sink or Swim Philadelphia

• Breathing Room Foundation

• South Jersey Cancer Fund

• National Marrow Donor Program

Crowd sourcing and fundraising

• Gofundme http://www.gofundme.com/medical-illness-healing/

• Indiegogo https://www.indiegogo.com/

• Youcaring http://www.youcaring.com/medical-fundraising

• Rally https://rally.org/

• Give Forward http://www.giveforward.com/

• Healthline http://www.healthline.com/health/online-medical-fundraising

• Causewish http://causewish.com/

• Host a local event: auctions, beef and beer, raffles---think outside the box!

Crowdsourcing Pros and Cons

Pros

• Helps gets the bills paid!

• Reaches large number of potential donors quickly• Potential for your story to go

viral

• Fosters a sense of community and solidarity

• Ease of use of websites for managing donations

Cons

• Potential for your story to go viral

• Fees involved with websites

• Potential tax liabilities for donor and recipient

• Donations given through crowdsourcing are not tax deductible unless they are given to a non-profit organization

Fundraising tips: telling your story• Who will the fundraiser support?

• This is your opportunity to tell (and sell) your story.

• Where is the medical treatment taking place?

• Who is the doctor?

• What exactly are the medical expenses?• Be as specific and detailed as you

can be. Your treatment center’s social workers, navigator and financial counselor can help you with this

• When is the money needed by?• Provide a sense of urgency by

stating a target date for funds to be raised

• Get the community involved and help bring awareness to your cause.• Think about community groups you

are involved in who can help rally support (PTA, running club, dog park)

• How will the money be used if the goal is met?• Formulate a solid plan for giving

back and paying forward.

• Reiterate where is the money going.• Ultimately donors are always going to

appreciate your honesty and being transparency

• SAY THANKS and show your appreciation

Conclusions

• Help is out there, you must be willing to share your story, ask for help and receive it.

• Get creative.

• Use fundraising and crowdsourcing to help achieve specific fundraising goals.

• Thank foundations and individuals for their help!

• Give back: pay forward.

QUESTIONS?

Contact information:

Christina Bach, MSW, MBE, LCSW, OSW-CEducational Content Specialist & Psychosocial Content Editor, OncoLinkwww.oncolink.orgchristina.bach@uphs.upenn.edu215-662-3221