What is Specialty Copay Assistance ?
Overview of Specialty Copay Assistance:
Specialty Copay Assistance are programs offered by manufacturers of specialty medications such as Humira, Prolia, Enbrel, etc. Specialty Medications are medications that are used to treat complex chronic conditions such as Cancer, Rheumatoid Arthritis or Psoriasis. Typically these medications are administered through injections or infusion rather than a standard pill format like common medications. American’s are developing these chronic conditions more commonly and many of these conditions are considered “Auto-Immune” disorders and most people are told they have no idea how they manifest (instead of recognizing it is likely from the ingestion and inhalation of the vast amount of poisons which are in the food and air).
The Steps of the Process:
Many patients are unaware of the cost of Specialty Medications because they are automatically enrolled in copay assistance programs either by their doctor or the pharmacy. When people find out they “need” these medications they typically are stressed and scared and are ran through a number of enrollments and new processes they do not understand. People who take specialty medications have to deal with a number of problems and the top of them is cost and most who are prescribed these medications are not given any information about the actuality of what they have been signed up for. So we are going to give you a breakdown of what typically occurs when these types of medications are prescribed.
Patient is DiagnosedYour MD will diagnose you with the condition for which a Specialty Medication is required.
Rx Sent to Specialty PharmacyThe doctor sends your prescription to a specialty pharmacy (which in many cases will be mandated by your insurance)
Doctor Submits Prior AuthorizationIn a high number of cases, a prior authorization will be required by your insurance. The MD must submit this and it must be approved.
MD or Specialty Pharmacy Will Sign You Up for Copay AssistanceEven with insurance the cost of the copays for these medications can be very high. Manufacturers offer copay assistance programs which you will likely be enrolled in or offered when you schedule the medication the first time.
The Cycle Continues Until…This cycle will likely continue for you without issue until you either A.) Lose your job or insurance coverage, B.) Until you turn 65 and begin to receive Medicare coverage.
Example Cost Cases:
Here are some different scenarios for the price of a specialty medication. For the example, we will use Humira which is commonly prescribed for treating Psoriasis or Psoriatic Arthritis; among other conditions. Since a one month supply of the medication can cost over $10,000 dollars it can be of severe consequence if you fall on hard times.
Scenario 1: No Insurance – Paying Out of Pocket
Scenario 2: Paying through Private Insurance Only
Scenario 3: Private Insurance w/ Manufacturer Copay Assistance
Scenario 4: Standard Medicare Part D without Low Income Subsidy
The Downside:
Specialty Copay Assistance Programs
Who does not qualify for Manufacturer Copay Assistance?
Commercially Insured
Unfortunate Event? Hello Problem
Approaching 65?
For those of you who have been taking these medications for years (essentially voiding the ability for you to heal yourselves through alternative methods) and are getting close to the age of Medicare, you will have a problem. Medicare is not considered commercial insurance coverage as it is funded by the government. Despite Medicare Part D being a supplemental coverage that many pay for, it does not qualify for copay assistance from the manufacturer. And while the cost of the medication for Medicare is much lower (strange isn’t it) whatever your copay is, that is what you will have to pay. So if the copay ends up being $300, that will be $300 that will have to be allotted each month for the medication to be continued.
What If I Can’t Afford It?
If you have received Medicare and cannot afford the copay amount for the medication, the only alternative that is available is certain grants and foundations that you may be able to qualify for. These are different than copay assistance and require financial information to be submitted in order to be approved. The income requirements differ and can be specified at the time of application. If you are on Medicare or are approaching the age, it would be wise to plan ahead for this issue as it is likely you will not find out about it until you provide your Medicare coverage to your Specialty Pharmacy and they attempt to refill the medication. Which may be a bit too late for many people. You can research such programs on Medicare’s Pharmaceutical Assistance search site
Beware of Sponsored Additional Programs through your insurance
PrudentRx is now essentially a method which is utilized to extort your deductible for your insurance plan first. What does this mean? If you were to have your insurance and copay assistance and were to enroll in PrudentRx, this would automatically limit your copay assistance from covering the full amount it normally would if your deductible was still outstanding. Which may cause you to have a copay of $2500 dollars at the time the medication is filled if you have not yet met your deductible. As long as you are enrolled in this program, a rejection will be given from the copay assistance program which will state that you are enrolled in a “maximizer program.” Essentially blocking the copay program from fully covering what it normally would until your deductible is paid.
So be cautious as while it still may give you a $0 copay, this may not be the case at the start of a new year when your deductible will be extorted. So it may be beneficial to not enroll in the plan. Be aware that you agree to this when you enroll. So it may be time to start reading those “terms and conditions.”
Leave a Reply