How exactly does a "Patient Assistance Program" work?

lets say my health insurance has a $3000 /year ductible, after which I pay 20% of costs up until an out of pocket maximum of $7000/year.

And let's say I wanted to start taking Rinvoq, or Zeposia, which look like they each have a real market price (GoodRx) of around $6000 a month.

So that looks like I'd be paying $72,000 per year without insurance, and after insurance I'd be well over paying my $7000/year out of pocket maximum.

But both of these say on their websites they have assistance programs where I "may" pay as little as $5/month. How exactly do these programs work?

Do they reimburse me for the deductible and out of pocket costs? That sounds a lot like insurance fraud.

Or do they strike some back room deal with my insurance company where I'd get out of paying my deductible and OOP? I can't imagine my insurance company voluntarily going along with that.

I'm on Humira's patient program. Income is irrelevant with these programs. Only requirement is that you have insurance. I have no idea how or why it works, but there is a coordination between the drug manufacturer and the insurance company. Humira out of pocket costs $7,000. Presumably, the drug manufacturer pays the insurance company $6,995 and I pay $5.

But that sounds way too simple, of course. My insurance actually required me to be on Humira. It was the only drug they approved. Which perhaps suggests that insurance and drug companies have some sort of arrangement to get people on specific drugs.

I have no idea how it works. But give the pharmacist your savings card number and like magic you will only be charged $5 (although you might be charged more until you reach your deductible)

I have a $3000 max out of pocket with my insurance. I've had different programs for different meds, but none of them were based on income. You just have to have private insurance and not be on medicare. When I was on Humira, I gave the co-pay assistance info to the pharmacy I was getting the med from and they took care of everything. When I was on Remicade, after insurance paid the hospital for all but my max OOP, then I had to send an EOB and the hospital bill to Remi's co-pay assisance program so they could load the funds on my co-pay card that I then used to pay the hospital. Now I am on Inflectra and since I am getting the med separately instead of through the hospital I gave the pharmacy the co pay assistance info and they took care of everything.

Having co-pay assistance for these expensive meds is the only good thing about this awful disease. I hit the max oop with my first infusion of the year and the rest of the year everything -- meds, labs, dr appts etc -- are fully paid for.

Based on what you said above:
if your dug is $6000/month
1st month you would be responsible for the $3000 deductible and $600 for 20% of the remaining $3000 or $3600 total. Your co-pay assist will likely cover all but $5 of that.
2nd month you would be responsible for 20% of $6000 or $1200 and again co-pay should cover all of that except $5
You will now have paid $4800 towards your max oop so you might have another 1 or 2 months like the 2nd month before you hit the OOP max. After that you won't be billed for anything. Insurance doesn't care who pays their deductible -- whether it's you or co-pay assistance.

CCinPA said...


Based on what you said above:
if your dug is $6000/month
1st month you would be responsible for the $3000 deductible and $600 for 20% of the remaining $3000 or $3600 total. Your co-pay assist will likely cover all but $5 of that.
2nd month you would be responsible for 20% of $6000 or $1200 and again co-pay should cover all of that except $5
You will now have paid $4800 towards your max oop so you might have another 1 or 2 months like the 2nd month before you hit the OOP max. After that you won't be billed for anything. Insurance doesn't care who pays their deductible -- whether it's you or co-pay assistance.

Under this scenario, does my deductible and OOP maximum actually get hit *for all my other purposes* as well, with only $5/month out of my pocket? IF so that would sound like an enormous benefit to me at the expense of my insurer.

Or does this special back-room deal between the manufacturer and my insurance company only affect this one drug? And it's handled separately from my normal deductible and OOP maximum?

Do you have separate deductibles/oop for drugs and medical? If so, not sure how that works. My insurance has 1 max out of pocket that covers drugs and medical so once I reach it the rest of the year all drugs, labs, doc visits etc are zero for me.

I don't question whether it's fair or not for the insurance companies. They got a lot of my money before I went on meds that had co-pay assistance -- that max out of pocket came out of my own pocket for years. I think the drug companies offer the co-pay assist to get patients on these expensive meds. Then after the oop is met, no more need for the assist so they get the full price.

I don't have a deductible for my prescription drug plan, but when I got Entyvio through a home infusion provider, the provider billed everything to my medical plan. I would have had to find a different infusion provider to have it billed differently. But then I found out about the patient assistance program and didn't have to change.