Patient Assistance: Goes Beyond Just Self-Pay Patients

Learn how patients beyond self-pay can utilize patient assistance

February 22, 2023
Billing statement

Patient Assistance Programs (PAPs) are programs offered by pharmaceutical manufacturers, non-profit organizations or government agencies that provide financial assistance and other forms of support to patients for their medication or medical care. A common misconception is these programs only support self-pay patients AKA uninsured patients. These programs support a wide variety of patients regardless of insurance status. Providers should consider all types of programs to maximize financial support and access for their patients.  

Summary of program types and supported patients:  

  • Manufacturer Copay Assistance Programs: Support commercially insured patients with their out-of-pocket responsibility.
  • Manufacturer Free Drug Programs: Support Medicare patients, uninsured patients, and denials associated with Medicaid, Medicare, and commercial patients.
  • Diagnosis-Based Assistance Foundations (DBAFs): Support Medicare/Medicare Advantage and Commercial for diagnosis-based causes. Very few foundations support self-pay patients.
  • Government and State-Based Programs: Program eligibility and details vary from state to state. There are a variety of programs including, low-income subsidy (LIS) which is offered to Medicare beneficiaries for their prescriptions; Qualified Medicare Beneficiary (QMB) which supports low-income Medicare beneficiaries for medical expenses, and oncology state aid programs which cover diagnostic and treatment expenses.  

What’s the best match for these types of patients and programs?

  • Commercial insurance: These patients have commercial insurance typically offered through their employer or purchased directly via a state public health insurance or federal marketplace. Despite having insurance, many of these commercial plans are structured so that patients still have large out-of-pocket (OOP) expenses for medical encounters and prescriptions.  

              Best match for OOP costs: Manufacturer Copay Assistance and DBAFs  

  • Medicare and Medicare Advantage: These patients are covered but also have exposure to high out-of-pocket costs. Medicare beneficiaries without a supplemental plan are especially at risk for high out-of-pocket costs.  

              Best match for OOP costs: DBAFs

  • Self-pay: These patients are uninsured or prefer to pay the self-pay costs since providers sometimes will charge a lower cash price than having to submit a claim to the commercial insurance plan.

              Best match for OOP costs: Manufacturer Free Drug, DBAFs, Government and State-Based Programs

Finding access to these programs can be very challenging for providers since there are so many programs and funding availability of DBAFs fluctuates routinely. If a DBAF runs out of money, it will close regardless of where the patient is at in the enrollment process. Utilizing a tech-enabled process is the best way to match patients to the right program at the right time.