Copay Assistance

How It Works

Copay assistance comes in three main forms. Manufacturer copay cards and coupons are offered directly by pharmaceutical companies for their brand-name drugs, typically reducing commercial-insurance patient cost to $0-25 per fill. These are prohibited for Medicare and Medicaid patients under the federal Anti-Kickback Statute (the Office of Inspector General treats them as illegal remuneration). Independent charitable foundations, PAN Foundation, HealthWell Foundation, Patient Advocate Foundation, Good Days, typically fund by disease state and serve both commercial and Medicare patients, though their operations are regulated by OIG advisory opinions to prevent manufacturer earmarking. Patient assistance programs (PAPs) run directly by manufacturers provide free drugs to uninsured or low-income patients, typically requiring documentation of income below 400-500% of the federal poverty level. Mark Cuban Cost Plus Drugs provides a different form of assistance by selling generics at acquisition cost plus 15% plus a $5 pharmacy fee, often cheaper than insurance copays even before any assistance. Copay assistance interacts with insurance through copay accumulators and copay maximizers, which are insurer strategies designed to prevent manufacturer dollars from counting toward the patient's deductible or out-of-pocket maximum. As of 2024, a growing number of states (including Illinois, Virginia, West Virginia, Arizona, and Puerto Rico) have banned copay accumulators on state-regulated plans.

Related Terms

• Copay Accumulator, An insurance policy that does not count manufacturer copay assistance toward the patient's annual deductible or out-of-pocket maximum, shifting costs back to the patient once assistance runs out.
• Copay Maximizer, A variant of copay accumulator that calibrates the patient copay for a specialty drug to extract the maximum available manufacturer assistance, spreading it across the year.
• Out-of-Pocket Cost, The amount a patient pays directly for a prescription drug, including copays, coinsurance, and deductible payments.
• Patient Assistance Program (PAP), A manufacturer-sponsored program that provides free or discounted drugs to patients who meet income and insurance eligibility requirements.