Support for Out-of-Pocket Expenses
Overview of Support Options
In addition to the Astellas Access ProgramSM, which provides Protopic at no cost to patients meeting the program eligibility criteria, support may be available for insured patients who have trouble affording their out-of-pocket (OOP) expenses for Protopic. Subject to meeting eligibility requirements, patients can receive support for their expenses for prescription drugs through manufacturer-sponsored product-specific programs or through independent, health condition-oriented financial assistance foundations.
Financial Assistance Foundations
Financial assistance foundations are independent, not-for-profit, charitable organizations that help patients with the costs associated with their healthcare needs. Assistance is usually provided across broad disease state categories, encompassing multiple products, treatments or therapies. Assistance is not specific to any one manufacturer or product, and assistance can be provided regardless of the drug or treatment the patient is currently taking. These foundations typically support underinsured patients (public or private), who cannot afford the out-of-pocket costs associated with their drugs and medications.
Terms commonly used:
- Coinsurance: the percentage of medical expenses and prescription drugs that the patient pays
- Co-payments: a set dollar amount the patient pays at the time of service for medical services and prescription drugs
- Deductibles: an annual fixed dollar amount that is capped per the patient's health insurance policy and must be paid by a patient before their insurance will pay for medical services and prescription drugs
- Health insurance premiums: the cost for participating in the plan that the patient pays, usually on a monthly basis
- Selected out-of-pocket healthcare costs: other costs like transportation for medical care or over-the-counter medication
Financial Assistance Foundation Eligibility
Criteria for patient eligibility vary among financial assistance foundations and are not influenced by Astellas Pharma US, Inc. Qualifying criteria usually include:
- Medical: disease state, patient's diagnosis, medication used
- Financial: patient's income and sometimes assets like savings accounts and investments
- Other: insurance type like Medicare or private insurance, amount of the co-pay or coinsurance levels, US citizenship or residence status
Financial assistance varies depending on the foundation and disease state. Support may be subject to annual caps or other restrictions.
To apply for assistance, the healthcare provider, patient, or guardian may contact the foundation directly. Additionally, Astellas Reimbursement ServicesSM (ARS) reimbursement specialists can assist patients with applying for financial assistance foundation support.
How Financial Assistance Foundations Work
Some foundations pay the pharmacy or provider on the patient's behalf. The foundation may set up direct billing relationships with certain retail pharmacies in the patient's geographic area. Other foundations issue benefit cards to patients and have established an electronic claims system, which allows:
- Patients to receive their drugs without paying upfront
- Pharmacies or physicians to submit claims electronically to the foundation
For Medicare Part D-covered products, assistance made on the patient's behalf may be considered an incurred cost by the patient and may count toward the patient's true out-of-pocket (TrOOP) obligation.
