The 2017 List of Financial Diabetes Patient Assistance Programs: How to Navigate Through the Process
Help is out there, if you are prepared.
We all know that diabetes is not cheap! From doctors appointments to testing supplies and medications the burden can be very heavy. But just as Integrated Diabetes Services is here to help you manage day to day life with diabetes, we are here to advocate for access and affordability as well. In the USA insurance is typically the primary payer for diabetes services. It is important that customers know their rights and their coverage. Working with prescribers to obtain prior authorizations to get medications covered takes time and energy, but it is important self advocacy that can save a lot of money, and make otherwise unaffordable resources available. But there are times when insurance simply does not cover a medication, or the remaining financial burden is too great. In these situations the drug companies themselves can be a valuable resource. But, just having a need and wanting a drug doesn’t get help.
Let’s walk through some of the programs offered by major diabetes pharmaceutical companies (Novo nordisk, Lilly, and Sanofi), and what you will need to apply.
First let’s identify what company you need to contact. On your medication packaging or insert it will list a company logo and name; this is the company you want to contact. Their websites are the best resource for applications and more information.
Now that you know what company you are applying to, who is eligible for these programs?
- First, if you are eligible for a generic of comparable medication through your current coverage you will likely be denied assistance. You can apply, but it is highly unlikely unless your prescriber is willing to write up a statement as to why you need that specific medication and can not use the generic or covered equivalent.
- Must be a citizen or legal resident of the United States *contact the specific program for eligibility in Puerto Rico or the US virgin Islands* (see programs specific to your nation of citizenship)
- You have been denied private insurance
- You must provide proof of application denial, typically from more than one carrier.
- You are not eligible for Medicaid (or CHIP program for children), VA prescription benefits, or Medicare
- You must provide proof of application denial
- If you have Medicare you must also have applied and been denied Medicare Low Income Subsidy (LIS) If you have Medicare but do NOT have Medicare part D, or have part D and spent:
- Novonordisk-$1000 or more on YOUR prescription medications in the current calendar year.
- Lilly: -$1100 or more on YOUR prescription medications in the current calendar year.
- Sanofi – have spent more than 5% of your HOUSEHOLD income on YOUR prescription medications in the current calendar year.
Kudos, you have made it through that obstacle course of requirements!
What are the income limits?
You still need to come in under income limits. These are based on your total (adjusted gross) HOUSEHOLD income. This includes all income earned from all members of your household. This includes yourself, your spouse, and all dependents (that’s right your teenager’s part time pizza delivery job factors in, as well as any income from investments)
What will you need: You will need proof of income, most recent W-2s, Federal tax return, Social Security benefits forms, or most recent month’s pay stubs will suffice. If you have had a recent income change due to loss of a job you will need documents of having applied for unemployment benefits, and what those benefits will be.
Novonordisk and Lilly require a total household income of less than 300% of the Federal Poverty level for your household size
Sanofi requires an income less than 250%
You can find those guidelines here: http://familiesusa.org/product/federal-poverty-guidelines
I will pause here to encourage you to discuss with your prescriber whether it might be worth switching a medication if you are ineligible for one company’s assistance program, but eligible for another.
What else do i need to do?
Now that you have your proof of denials, financial records, and probably a headache, head to the company program websites listed below and print off a copy of the application. Be sure to also print off any accompanying HIPAA release forms. Complete and sign the patient portions of the application and take it to your healthcare provider. They will need to fill in their portion, including your medication orders, and sign.
Finally you are ready to fax or mail in your entire application packet. Include the completed application, HIPAA form, Proof of denials and proof of income. These are faxed or mailed to the program address listed on the website. If mailing MAKE COPIES OF EVERYTHING! Don’t send your originals; you will need copies in case something gets lost.
And now, you wait. It typically takes a couple of weeks or more before you will be contacted by the program to let you know whether you’ve been approved. Assistance plans dictate their level of coverage and duration of coverage. Typically patients get a 120 day supply for up to one year free of charge. These are typically sent to the patient’s prescriber. Your prescriber will have to complete an additional form for each 120 day refill. All approvals are good for one year and you will need to reapply for the next year. Never assume you will be approved as guidelines for income and eligibility change annually.
Congratulations! You made it through the patient assistance process. (Not to mention one rather long and confusing article!) Help is out there, it is rarely easy, but no one should ever go without the life sustaining medications they need.
For more information on the Patient Assistance programs mentioned in this article: