Cost-Sharing Collection Policy & Financial Hardship Waiver

As patient cost-sharing expenses increase, the corresponding obligation of a pharmacy to ensure compliance with all rules applicable to collection of patient cost-sharing responsibility increases as well. Medicare, Medicaid, and PBMs all have various rules and requirements pertaining to cost-sharing collection. This program provides parameters for when InnovaRx (the "Pharmacy") may grant waivers to patients of cost-sharing responsibility.

InnovaRx is committed to complying with federal and state laws and PBM requirements concerning collection of patient cost-sharing responsibility. At the same time, the Pharmacy recognizes that lack of access to healthcare, including potentially life-saving drugs, is an all-too-common issue, and is committed to an ethical, compassionate, and socially just policy of providing access to high-quality healthcare to all patients. To address situations in which patients cannot pay cost-sharing obligations because of financial hardship, InnovaRx has created this Cost-Sharing Collection Policy & Financial Hardship Waiver Program.

The Pharmacy's obligations with respect to collection of patient cost-sharing responsibility arise from multiple sources, including federal and state law, Medicare and Medicaid rules and regulations, and third-party payor (such as PBM) contractual obligations found in pharmacy provider agreements and manuals.

The general rule is simple: the Pharmacy must collect patient cost-sharing responsibility. This is required by all commercial and governmental third-party payors, subject to limited exceptions. Routine waivers of patient cost-sharing obligations are not permitted because such waivers misrepresent the Pharmacy's actual charge and may result in false claims. The U.S. Office of Inspector General has indicated that granting routine waivers of Medicare/Medicaid patient cost-sharing responsibility may violate the Federal Anti-Kickback Statute.

There are, however, exceptions to this rule when a patient is unable to afford their cost-sharing responsibility. This Program sets forth procedures the Pharmacy will follow before any cost-sharing obligation is waived. Generally, InnovaRx may waive a patient's cost-sharing obligation only after the patient demonstrates a financial hardship.

Routine Waivers. Routine waiver of patient cost-sharing responsibility is strictly prohibited by Medicare regulations and the terms of third-party payor/PBM agreements. Every waiver is carefully considered and assessed on a case-by-case basis. A waiver cannot be funded by a third-party program, although InnovaRx may legitimately participate in copayment coupon or rebate programs.

Advertising of Waivers. InnovaRx does not advertise or otherwise promote the waiver of patient cost-sharing responsibility, and Pharmacy personnel are strictly prohibited from doing so. Pharmacy personnel may not initiate a discussion of the patient's inability to pay. If a patient volunteers that they cannot afford their cost-sharing responsibility, Pharmacy personnel will direct the patient to submit an Application for the FHW Officer's review. Only the FHW Officer may authorize a waiver.

Medicaid Enrolled Patients. Under New Jersey State and federal law, Medicaid patients may not be denied their medications due to inability to pay cost-sharing responsibility. If a Medicaid enrollee indicates financial inability to pay their cost-sharing responsibility, InnovaRx will dispense the medication and document the patient's statement in their file.

FHW Application. When a patient requests a waiver, InnovaRx will require completion and submission of the Financial Hardship Waiver Application. Applications may be provided by email, fax, mail, or in person. Patients must provide all documentation requested in the Application to be eligible.

Expiration & Updates. The Pharmacy may rely on submitted documentation for 12 months, unless the patient notifies the Pharmacy of changes. At expiration, a new Application and updated documentation must be submitted to renew the waiver.

Supporting Documentation. Supporting documentation may include tax returns, bank statements, pay stubs, medical bills, or evidence of: homelessness; enrollment in WIC; receipt of food stamps; participation in a subsidized school lunch program; participation in an unfunded state or local assistance program; or residence in low-income, subsidized housing.