It’s a scenario that’s all too common in healthcare: a patient receives a diagnosis calling for an expensive therapy. And for the most effective treatment the drug must be started immediately, but the patient is unable to pay without risking their financial security. Nearly one in four patients in America have reported that they have difficulty covering their medical costs. A recent study by the Kaiser Foundation found that in the interest of cost, 29% of Americans failed to take their medications as prescribed, ultimately skipping doses or skipping the prescription entirely.
There are a handful of reasons for this. The patient may be uninsured; according to the U.S. Census Bureau, 8.6% of Americans lack health insurance. The patient could also be underinsured, lacking prescription drug coverage that fully covers the therapy. The patient could be functionally uninsured, meaning that they are fully insured but the medication isn’t on the healthcare plan’s formulary or the patient has been denied prior authorization. Or the patient’s insurance company could have agreed to consider covering the drug, but there is a gap in time while they complete their review.
As a manufacturer, you believe that your therapy should be placed in the hands of any patient who needs it, whenever they need it. Getting past these obstacles while maintaining regulatory compliance is tricky, but many manufacturers have developed a workaround: patient assistance programs. These programs form a safety net for eligible patients who are unable to afford their medication. They also serve an important clinical purpose by speeding access to therapy and encouraging adherence.
Patient assistance programs are typically sponsored by a manufacturer’s endowed foundation. A PAP foundation can offer assistance to eligible patients in a number of ways. Below, we’ll discuss traditional patient assistance programs, quick-start programs, bridge programs, co-pay assistance, and how you can empower your patients to access their medication when they face financial hurdles.
Traditional Patient Assistance Programs
Traditional patient assistance programs supply ongoing medication to eligible patients at reduced or no cost. These patients are uninsured, functionally uninsured, or facing prior authorization or formulary barriers. Manufacturers vary, but patient eligibility is always based on income. Most manufacturers have eligibility requirements like the following:
- The patient must meet income guidelines based on the Federal Poverty Level
- The patient must have a valid prescription written by a U.S.-licensed provider
- The patient must demonstrate a lack of adequate insurance coverage
- The patient must reside in the U.S.
Patients, collaborating with their healthcare providers, apply by submitting an enrollment application. Proof of income must be furnished. In some cases, manufacturers require that patients seek other types of assistance before applying.
Quick Start Programs
Quick start programs are designed to help patients start their therapy quickly by providing them with a temporary supply of a drug. Often, commercially insured patients who have been newly prescribed a medication face a short delay while their insurance conducts verification. Eligible patients receive enough medication to last 5-30 days, depending on the manufacturer. You can opt to ship the medication directly to the patient, or to provide a coupon or voucher that a patient can use at their pharmacy.
Working with their healthcare provider, the patient must prove that they are insured and experiencing an insurance-related delay, are new to the therapy, and have been prescribed the drug for an FDA-approved indication.
Quick start drug programs can also be useful when you’re ending a trial. In these cases the patient has already been taking the drug, but their access to it has changed. With a temporary supply program you can bridge the gap between a drug’s trial and its commercialization, ensuring continuity of care.
Pharmaceutical bridge programs provide eligible patients temporary access to a medication when they’re facing a disruption in their insurance coverage. Usually these patients have already been taking the drug, and a job change or other life event means that their coverage has been discontinued. They may also be experiencing a delay in prior authorization. When this happens, you can opt to provide a “bridge” supply of the drug until the patient can resolve their insurance problems. Temporary supply programs are also useful when you have a drug that requires a clinical observation period.
Most manufacturers who offer bridge programs do so based on financial eligibility. In some cases, patients must prove their current insurance status to qualify. Extending bridge programs to patients not only helps them financially, but it also encourages adherence and better patient outcomes.
Many Americans who are commercially insured still struggle to manage prescription copays or must work around high deductibles. For these customers, you can ensure that they receive their therapy by offering assistance with prescription copays regardless of their income. Some manufacturers choose to offer financial assistance to defray the cost of copays. This approach is usually funded by medical foundations or patient groups. A patient can apply individually, or a pharmacist or provider can apply on a patient’s behalf.
You can also offer copay assistance with manufacturer vouchers or coupons. This strategy can reduce a patient’s copay or eliminate it entirely. You can offer the coupons directly to a customer, or the patient’s physician can dispense them when the medication is prescribed. When the patient presents the coupon at the pharmacy, the pharmacy applies a discount to the patient’s established copay. The pharmacy then submits a claim to the manufacturer, and the manufacturer pays the balance of the copay on the patient’s behalf.