Patient Access & Affordability

01Why Copay Cards Don't Work for Government-Insured Patients

The federal Anti-Kickback Statute (42 U.S.C. § 1320a-7b) prohibits manufacturers from offering anything of value — including copay cards — to induce a Medicare, Medicaid, TRICARE, or VA beneficiary to use a particular drug. Manufacturer copay cards are generally only usable by commercially (privately) insured patients.

02Manufacturer Patient Assistance Programs (PAPs)

PAPs are manufacturer-run programs that provide medication free or at deeply reduced cost directly to eligible patients — typically uninsured or underinsured — based on criteria like income and insurance status. This is separate from a copay card and is a compliant option for government-insured patients who qualify.

03Independent Charitable Foundations

Per HHS-OIG guidance, an independent charitable foundation can appropriately help government-insured patients only if it is truly independent of any single manufacturer, supports a disease state broadly rather than one specific product, and makes assistance decisions without manufacturer influence over individual patients.

04Medicare Extra Help / Low-Income Subsidy (LIS)

Extra Help is a federal program (also called the Part D Low-Income Subsidy) administered largely through Social Security that helps eligible low-income Medicare beneficiaries pay their Part D premiums, deductibles, and copays.

05The Part D Annual Out-of-Pocket Cap

Created by the Inflation Reduction Act of 2022, Medicare Part D now has a hard annual cap on a beneficiary's out-of-pocket drug costs — $2,000 in 2025, rising to $2,100 in 2026. Once a patient hits the cap, they pay $0 for covered Part D drugs for the rest of the calendar year.

06Medicare Prescription Payment Plan (Smoothing)

Also created by the IRA, this voluntary program lets a Medicare beneficiary spread their Part D out-of-pocket costs into monthly payments across the plan year instead of paying it all at the pharmacy when a prescription is filled. It improves cash flow but does not reduce the total amount owed.