Qualifying with Medication Co-Pay Assistance for Specialty Medications

This post was written by Sandy Hope, Funding Specialist, and Justine Dolorfino, Social Media Specialist & Communications at Diplomat.

Did you know that foundations and grants exist that may help patients afford their important specialty and limited-distribution medications?

Getting started with co-pay assistance

Each foundation has designated disease states or medical conditions that they support. Some diagnoses can be covered by several foundations. Others are only supported by one or two foundations. This can make it more difficult to find funding for some medical conditions because of a lack of funds available or because there is not enough funding for certain diagnoses.

In addition, some foundations are diagnosis and drug specific. This means that in order to qualify for funding, the diagnosis and drug prescribed must both be supported by the foundation. As part of the application process, the prescribing physician is required to complete and sign a section of the foundation’s application verifying the diagnosis and drug(s) prescribed.

What are some other factors that are considered?

Most foundations will consider the household size and income and have predetermined income schedules as part of their financial guidelines. To qualify, the household income cannot exceed the guidelines of the respective foundation. Proof of income is a prerequisite and is generally satisfied through the submission of the patient’s most recent federal tax return. If the patient is not required to file taxes, then he/she is asked to submit alternate documentation such as a copy of his/her (and spouse’s if applicable) social security award letter, a bank statement showing income deposits, and a pension statement if applicable. The documents are to be submitted along with the foundation’s respective application.

Lastly, foundations are not designed to cover the total cost of the drug; rather, they are intended to help cover the patient’s co-pay amount. Because of this, patients are required to have Rx coverage or medical insurance that participates in the prescription cost. This is verified by reviewing a copy of the patient’s insurance cards.

What kind of assistance is provided?

Once a patient has qualified, the foundation will provide a specific amount of money that will go towards the out-of-pocket co-pay. In most cases, the award is available for up to one year or until the grant amount has been used, whichever occurs first. The amount provided is most often based on the patient’s diagnosis.

Foundations are aware of the pitfalls of Medicare Part D coverage and the gap period (donut-hole) a patient faces when taking costly medicines. Some foundations are able to award enough to help patients through this period, but some do not. Because of this, some patients may need to find additional funding assistance to help them move through the gap period.

How do I begin the process?

Though we have covered some of the main criteria considered by foundations, many have additional requirements. The process can be time consuming and confusing. Working with a funding specialist can make the process of finding and qualifying for co-pay assistance much simpler.

image001At Diplomat, we put a lot of effort toward helping our patients obtain co-pay assistance through these foundations. Our trained staff will help patients determine which foundation is best for them based on their particular circumstance and their diagnosis, drug, household size and income, and insurance coverage. We are continuously seeking out additional foundations and resources for our patients.

If you have questions about co-pay assistance, please feel free to to email or call us at 1.877.977.9118 for more information. Or, to learn more about our funding assistance services, browse the Diplomat Co-Pay Assistance Navigator Program or fill out our confidential online form at our website.

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  1. Please help me with assistance with my Cimzia script. I am on medicare and I cannot afford it. I will submit whatever paperwork you ask me to get the script. I have Lupus and RA and othe auto immune diseases and spinal issues that can be documented if needed.

  2. Please help m with my Creon 36000 prescription. I have Pancreatic Cancer and need the replacement enzyme to digest food. The cancer has also resulted in Type I Diabetes which requires insulin. I am on Disability and can’t afford $500.00 a month co-pay just for these 2 prescriptions. Thank you!

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Welcome to the NeedyMeds Voice! We look forward to presenting you with timely, provocative pieces on healthcare reform, patient advocacy, medication and healthcare access, and other health-related news. Our goals are to educate, enlighten, and elucidate; together, we will try to make sense of the myriad and ongoing healthcare-related changes in the U.S. today.