Co-Pay Assistance 101

What is co-pay assistance?

Co-pay assistance is financial assistance that helps pay for co-pays for patients WITH insurance - but who are underinsured. Underinsured means you have out-of-pocket costs that are not covered by your health insurance and that you cannot afford.

This can include:

• Premium- What you pay for your health insurance.
• Deductible- How much money you must pay before your insurance coverage begins to pay.
• Co-pays- A fixed amount for medical care. Example: You have a $20 copay for an office visit.
• Co-insurance- Cost sharing. The insurance company pays for a part of your care, and you pay for a part of it. If a plan is an 80/20 plan, your insurance pays for 80% of the costs and you pay for 20%.
• Maximum Out of Pocket- When you meet this amount every year, you will then be covered at 100%.
  • For example, Your maximum out-of-pocket is $5000. When the total of your deductible, plus copay, plus coinsurance reaches $5000, you will be covered at 100%.
  • Premiums do not count towards the maximum out-of-pocket.

What co-pay assistance is available?

There are many foundations that are funded by both pharmaceutical companies and other donors that give financial assistance for co-pays and out-of-pocket medical expenses. To qualify for copay assistance, you must

• Have a cancer diagnosis that is covered by the fund available.
• Meet financial criteria to qualify for assistance.
  • Each co-pay foundation sets its own income requirements to receive assistance. These may be at 300-600% of the FPL (Federal Poverty Level).

These funds also have a listing of what medical costs may be covered by their co-pay assistance.

• Some co-pay assistance foundations will cover the cost of office visits co-pays ONLY IF you are receiving treatment on the same day. If you are only seeing your provider that day and not getting treatment, they may not cover that day’s co-pay.
• Some foundations can also cover insurance premium payments.
• You can receive assistance from more than one foundation.

Organizations provide co-pay assistance to people with cancer

• Cancer Care Copay Foundation
• The Leukemia and Lymphoma Society Co-Pay Assistance Program
• Patient Advocate Foundation Co-Pay Relief Program
• The Chronic Disease Fund GoodDays Program
• The Healthwell Foundation
• Accessia Health
• National Association for Rare Disease (NORD)
• Patient Access Network Foundation
• The Assistance Fund

Each of these organizations gives assistance for different kinds of cancer and treatments. A helpful resource for finding what funds are open for your disease type is called Fund Finder.

What isn’t covered by co-pay assistance?

• Co-pay assistance does not pay for travel, lodging, or office visits unless you are having treatment on the same day as that office visit.
• You can’t get co-pay assistance if you don’t have insurance.
• Treatments that are denied by your insurance company are not covered by co-pay assistance.
• Experimental or non-approved treatments are not covered.
• Co-pay assistance (private foundations) is not the same as 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 cover experimental, non-approved treatments.

What is a co-pay card?

Co-pay cards are offered by drug companies to help with paying for drug costs. They are only for

patients who have private/commercial insurance. They do not apply to patients with Medicare Part D RX plans or Medicaid.

Where can I get help with co-pay assistance?

Your oncology social worker or navigator should be able to help you with the process of finding programs you may be eligible for, as well as helping with applications. Be sure to let your team know if you are having trouble with the cost of treatment.