Know Your Co-Pay Assistance and Training Rights - A $1600 Lesson

There’s something that has stirred my grits at a slow churn over the past couple of years. It’s something I’m seeing pop up in groups far too often. I find it rather alarming, too. I can’t seem to wrap my head around the issue because it feels like something easily avoided. Patients are taking to social media about receiving their new biologic medication, at home, without training. They are asking the Internet how to inject. Medicines worth tens of thousands of dollars are shipped to patients who've never injected a thing.

Awareness of resources for assistance programs is low

Far too many have reported receiving injectable meds at the home without a nurse coming to train them or going to an office to receive that training. Needless to say, it stirred some feelings inside. I started asking some of the posters if their doctor ever offered training or if they asked their insurance company. Of the four people I can think of off the top of my head the answers were all, “No.”

Fair enough…

Another question I ask if they were aware of the co-pay assistance program. If they respond, “No,” I inform them of the program that goes with their medication. I also ask them if they have commercial insurance or something different, so that I can get additional phone numbers for them should they have an issue with helping to pay for the medication.

Your rights as a patient

Why my grits got stirred.

These questions I’m asking – this information I’m seeking out and forwarding on – while yes part of being an advocate for some people, is a job that medical offices should be performing. It leaves me baffled that patients are not aware of their rights.

Specialists and their staff members should be informing their patients of training programs available by the various injectable companies. Some of them even have RNs who establish a relationship with the patients to help train them on the med, help with compliance, and assist them with insurance and paperwork issues. These advocates will train the patient and their caregiver on how to inject. Another great thing a lot of people are unaware of is that some insurance plans are also offering additional resources like RN advocates. These advocates help those with chronic illnesses navigate their health plans. They also administer medication as well as provide injection training.

Navigating insurance issues

Here’s my real-life example: Last week I spent over 5 hours on the phone with insurance issues. So, I called my medication’s RN advocate and left a message. This past Monday she called to follow up and confirm info and create a plan. By Thursday, three tasks that would have taken me hours to navigate were completed by the RN advocate.

Secondary to patients not being informed about potentially receiving training, I experienced a pharmacy rep who didn't go out of their way to notify about patient co-pay assistance to reduce out-of-pocket cost. I had to prompt them.

How much does the medication cost?

Here’s my real-life example: In September of 2016, I was set to start on a pill-form biologic. Although some people argue that it’s not a biologic, I argue, “If Johns Hopkins’ arthritis center says it is then that should hold water.” But I digress...

I received a call from the specialty pharmacy provider. I tried explaining it was a bad time but the Rep pushed forward with the call. I expected to hear my co-pay was $0, 5 or $10. Then, they hit me with major sticker shock. I told the rep I must have heard them incorrectly, and asked if they could repeat.

Once again, I was told it would cost $1,600 out of pocket. I laughed and asked where that money was supposed to come from?

Not that they cared. But still. I then said, “Is that with co-pay assistance or without?”

Advocating for yourself

This changed how I viewed pharmacy billing practices. It is also why I worry about patients financially hurting because they didn't know any better.

The moment I said co-pay assistance, the Rep’s tune changed. “Oh, I can help you with that.”

I was thinking it would take an hour of paperwork on my end. I also was picturing having to send it over to my specialist’s office for them to fill out, which also would cost money because they charge for that. Nope.

It is shocking. Within 5 minutes, the Rep pushed a digital application for patient assistance for that new pill-form biologic med and voila, accepted with a $0 co-pay for a 90-day supply. I went from $1,600 to $0 mighty quick.

I consider this situation my $1,600 lesson.

Remember, if you receive a new prescription for an injectable medication, it's okay to ask for help.