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IPD'S DRUG & CLINICAL REVIEW:
PATIENT FINANCIAL ASSISTANCE PROGRAMS 101

"Probably the first one that comes to mind are coupons or copay card programs. These are basically just what they sound like: coupons or cards that patients can use to get a discount on those out-of-pocket costs of their medications. Now, there's a lot of variability in program values and how they work. Some programs have minimum or maximum copay amounts and have limits like maximum savings per script or per year, or they could also have a maximum number of fills per year.

and these programs can cover drugs on either the pharmacy or medical benefit. For medical benefit drugs, patients may have to mail in an explanation of benefit or some other evidence of payment and then get reimbursed by the manufacturer after the fact. This is because, unlike medications on the pharmacy benefit, which can apply the savings right away during adjudication, medical benefit claims are processed later. So, the patient's out-of-pocket cost isn't known at the time of service.

Obviously you have to be prescribed the drug and usually manufacturers stipulate that it must be for an FDA-approved indication. Besides that, these programs almost always include patients with commercial insurance and sometimes they include patients without insurance coverage at all. Occasionally they may include patients with Medicare, but often there are certain restrictions that apply; most other government-sponsored insurance like Medicaid is pretty consistently excluded."

Our Executive Clinical Pharmacy team talks through the basics of patient financial assistance programs and their impacts on the healthcare space.

 

Topics included in this episode:

  • Overview and Basic Definitions of Patient Financial Assistance Programs

  • Coupons or Copay Programs

  • Free-Trial Programs

  • Bridge Programs

  • Patient Assistance Programs

  • Payer Strategies

  • Accumulator and Maximizer Programs

  • Program Impacts on Payers

  • Regulatory Implications of These Programs