Manufacturer copay cards are supplemental payments, often used in combination with commercial or private insurance plans, to lower patients’ out-of-pocket costs. These cards are typically seen in a pharmacy setting to help lower brand medication costs. Although they are less well known, there are also medical claim copay cards that serve the same purpose for clinician-administered products. These copay cards are traditionally seen in outpatient clinics and facilities.
Generally, the claims submission process is consistent amongst the various manufacturers offering medical benefit copay cards. When an eligible patient is receiving an infusion administered in an outpatient setting, the facility will bill the patient’s insurance as the primary payer and the copay card as the secondary payer. After the insurance pays its portion, the Explanation of Benefits (EOB) will determine the enrollee’s out-of-pocket drug cost. Physicians/patients must submit an EOB within a specified time limit (typically 90 days), in addition to submitting a completed CMS 1500 / UB-04 form to the manufacturer. Once enrolled, the new member is provided with member information and possibly a copay credit to use as a form of payment.
Some outpatient practices partner with companies to assist in the reimbursement process. Those companies coordinate with the manufacturers and deliver the claim information (i.e., date of service, amount due, etc.) to process the payment. Upon approval, the payment will be applied to the patient’s account to reduce their annual benefit allowance.
Many manufacturers offer these medical copay cards for medications that are to be administered safely by a trained healthcare professional. Presumably, each manufacturer has certain requirements and limitations to determine eligibility for their copay programs. Detailed terms and conditions associated with these copay cards generally surround the included plan types, the maximum annual benefits, rebate limitations, and more.
A variety of manufacturers offer medical benefit copay cards. For example, LEQVIO, manufactured by Novartis, has a medical benefit copay card for eligible, commercially-insured patients. However, since this medication is administered by a healthcare professional, the financial flow may be somewhat different than what we see under the pharmacy benefit; as stated in the card’s terms and conditions, “For patients covered under the medical benefit, rebate for out-of-pocket costs will be assigned directly to provider, unless patient requests direct reimbursement.” Bristol Myers Squibb (BMS) also explicitly outlines terms and conditions for using medical claim copay cards with several of their products. They state that “The program benefits are limited to the co-pay costs for BMS medications covered by this Program that the patient receives as an outpatient. The Program will not cover and shall not be applied toward the cost of any dosing procedure, any other healthcare provider service, supply charges or other treatment costs, or any costs associated with a hospital stay.”
Due to the Anti-Kickback Statute, patients under Medicare, Medicaid, TRICARE and other government programs are not eligible for these programs.
With the rising cost of medications, patients are constantly looking for ways to reduce financial burden. By understanding and utilizing medical copay cards, providers can help patients lower out of pocket costs, ultimately improving access and adherence.
Source: Terms and Conditions