Billing Coupons for Medicare Part D Patients – When Is It Okay?

The Patient Access Network Foundation (PAN Foundation), that work as non-profits to help patients receive otherwise unaffordable treatment. The PAN Foundation website offers a section called PAN’s OIG Advisory Opinions and Bulletins that helps address how independent charitable patient assistant programs (PAPs) can maintain compliance with federal laws, regulations, and guidelines while providing cost-sharing assistance to Medicare Part D patients.

In the article OIG Special Advisory Bulletin on Patient Assistance Programs for Medicare Part D Enrollees, the OIG concludes that, “pharmaceutical manufacturer PAPs that subsidize Part D cost-sharing amounts present heightened risks under the anti-kickback statute. However, in the circumstances described in this Bulletin, cost-sharing subsidies provided by bona fide, independent charities unaffiliated with pharmaceutical manufacturers should not raise anti-kickback concerns, even if the charities receive manufacturer contributions.”

Be careful treading these waters as there have been previous concerns about the legitimacy of some of these charities. While PAAS National^® cannot determine whether a specific copay card meets the requirements, the OIG has an advisory opinion process for individuals or entities that want affirmation that they will not infringe on fraud and abuse laws. Visit Advisory Opinion FAQs for more information.

PAAS Tips:

• Do NOT bypass primary insurance coverage requirements, including step-therapy, quantity limits, or prior authorization requirements
• Utilize the correct ‘Other Coverage’ code indicator
• Use caution with state employees, check with your State Department of Insurance or the state’s employee health plan for clarification
• Many manufacturers will have different programs/cards for insured and uninsured patients. View manufacturer websites or check with the prescriber to discover an alternate program/card that may work for the patient
• Be sure to adhere to the Terms & Conditions (T&C) of the various copay cards. By processing a claim, you are inherently agreeing to these T&C, which often spell out exclusions, etc.