Copay Assistance and Patient Support Programs

The cost problem

Many of the most effective medications in rheumatology — biologics, JAK inhibitors, and other specialty drugs — carry list prices that can run thousands of dollars per month. Even with insurance, your copay or coinsurance can be substantial. A 20% coinsurance on a $5,000 medication is $1,000 out of your pocket.

The good news: you almost never have to pay that full amount. A range of assistance programs exist specifically to bring your costs down — sometimes to zero. The challenge is knowing what’s available and how to access it. That’s where we come in.

Manufacturer copay cards

Most pharmaceutical companies that make biologic and specialty medications offer copay assistance programs for patients with commercial (private) insurance. These work like a secondary payment that covers most or all of your copay.

• Typical benefit — $0 to $5 out of pocket per fill or infusion
• How they work — the manufacturer provides a card or enrollment number that your specialty pharmacy applies to your prescription, covering the difference between what your insurance pays and the total cost
• Eligibility — you must have commercial insurance (employer-sponsored, marketplace, or individual plans); most programs exclude government insurance (Medicare, Medicaid, Tricare, VA)
• Duration — most programs renew annually, and some have a maximum annual benefit (usually generous enough to cover a full year of treatment)

Your specialty pharmacy will often ask if you have a copay card when they call to arrange your first shipment. If you don’t have one yet, they can usually help you enroll on the spot.

Foundation assistance programs

If you have Medicare, Medicaid, or are uninsured — or if your manufacturer doesn’t offer a copay program for your specific situation — independent foundation programs may be able to help.

• PAN Foundation (Patient Access Network) — provides copay assistance for patients with specific diagnoses, funded by charitable donations
• HealthWell Foundation — similar to PAN, covering copays, premiums, and travel costs for eligible patients
• NORD (National Organization for Rare Diseases) — assistance for patients with qualifying rare conditions
• Chronic Disease Fund — copay and premium assistance for chronic illness patients
• Good Days (formerly CDF) — financial assistance for patients with chronic or life-altering diseases

Each foundation has its own application process, eligibility criteria, and funding availability. Some open and close enrollment throughout the year as funds are replenished. Availability changes frequently — a program that was closed last month may have new funding today.

How to apply

Getting started is usually straightforward.

• Manufacturer programs — visit the drug manufacturer’s website or call the number on the program’s materials; enrollment is often online and takes 10 to 15 minutes
• Foundation programs — apply online or by phone; you’ll typically need your diagnosis, insurance information, household income, and a doctor’s signature (which we provide)
• Specialty pharmacy assistance — your specialty pharmacy often has a dedicated team that identifies and enrolls you in available programs — let them help
• Our office — if you’re not sure where to start, ask us; we can point you in the right direction and provide any documentation the program requires

What these programs cover

Depending on the program, financial assistance can help with:

• Copays and coinsurance — the most common type of assistance, covering what insurance leaves behind
• Deductibles — some programs apply payments toward your annual deductible
• Premiums — a few foundation programs help with monthly insurance premiums
• Full medication cost — for uninsured patients, some manufacturer programs provide the drug at no cost through patient assistance programs (PAPs)

If you are uninsured and need a specialty medication, tell us. Most manufacturers offer free drug programs for patients who meet income guidelines. These are separate from copay cards and can provide your medication at zero cost.

Important things to know

• Programs change frequently — funding levels, eligibility rules, and covered medications shift throughout the year; always verify current availability before assuming coverage
• Annual re-enrollment — most programs require you to re-enroll each calendar year; don’t let your coverage lapse accidentally
• Medicare restrictions — federal law prohibits manufacturer copay cards for Medicare patients, which is why foundation programs are especially important for this group
• Accumulator and maximizer programs — some insurance plans have adopted policies that prevent copay card payments from counting toward your deductible or out-of-pocket maximum; if your plan uses one of these, let us know so we can explore alternatives

Our commitment

We will never let cost be the reason you don’t get the treatment you need. If you’re struggling with medication costs — or even just worried about what a new prescription might cost — talk to us. We’ve helped many patients find assistance, and there is almost always a path forward.

This handout is provided for educational purposes and does not replace individualized medical advice. Always follow the specific instructions given by your rheumatologist.