What You Need to Know About Non-Medical Switching

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Six in ten adults in the US have a chronic disease. Chronic disease is defined as heart disease, cancer, chronic lung disease, stroke, Alzheimer’s disease, diabetes, chronic kidney disease reports CDC.gov . With so many people having to manage chronic disease, the key is finding the right doctor. Finding the right doctor is very personal, several factors play a role in this decision including communication style, personality, availability, and of course competence. The journey is not over once a good physician is found. The patient and physician spend a lot of time and effort finding the proper medications to treat or manage the symptoms of chronic disease. For many conditions such as hypertension and diabetes, it can take trying several different medications to get the best result for the patient. 

Now imagine after many months or even years, the patient and doctor have found the correct medication regimen. The patient has improved their quality of life and eased the fears that come with chronic illness. Along comes the patient’s insurance company, telling the patient that their medications are no longer covered by their plan. Now the patient and doctor must start over to find new medications that may not be as effective not because their medicines are not working but because of cost. The insurance company has put themselves in the middle of the patient-physician relationship, this is an example of non-medical switching. Non-medical switching of medication, whereby a patient’s treatment regimen is changed for reasons other than efficacy, side effect, or adherence, is often aimed at reducing drug costs reports ncbi.nlm.nih.gov . 

Insurance company policies, like step therapy and non-medical drug switching, that prioritize cost-curbing over patient needs and a physician’s medical judgement can seriously compromise patient safety reports acponline.org. Insurance companies can use several of these cost cutting tactics on the patient. The first and most obvious method is when the medication regimen that the patient has been on is suddenly no longer covered under the patient’s formulary. Insurance companies can also decide to increase the patient’s copay, making the medication too expensive for the patient to afford. Most commonly, insurers use therapy tiers or step therapy to define what the out-of-pocket copay is for medication. Tier one is where the plans usually begin, and this covers generic medication and has the least out of pocket for the insured. Each tier goes up in cost related to brand name drugs and if they have generics available. The most expensive tier to the insured is specialty drugs for serious illness. Step therapy is often called fail first therapy. These policies restrict coverage of expensive therapies unless patients have already failed treatment with a lower-cost alternative reports healthaffairs.org . 

Although formulary restrictions may decrease drug costs, several studies have demonstrated that total healthcare costs remained the same or increased reports pharmacytimes.com .  Changes to longstanding drug regimens for patients require more doctors appointments and lab testing to get the disease symptoms stabilized again. Often, the patient needs to use the services of an emergency room and a hospitalization to get symptoms under control. The newly prescribed medications forced upon the patient and doctor can have new side effects and medical complications. Generic medications are pushed upon the patient by the insurance companies and often doctors are offered incentives to prescribe those medications. The problem is that not all generic drugs are made equal. Some can be more or less potent than the medicine they’re mimicking, release doses into the bloodstream incorrectly, or contain impurities- sometimes to dangerous effect reports pharmaceutical-technology.com . 

Chronic illness is by definition long-lasting and should be managed by the patient and doctor. When insurance companies cross that boundary and insert themselves into the middle of that relationship, there are steps the patient can take to protect themselves. It is important to find a doctor that is always easily accessible to communicate with. A doctor’s office with an after-hours line and a patient portal available make it easier to communicate prescription and insurance issues as they arise. A patient can reach out to state law makers for help in instituting legislation to regulate insurance companies. Legislation needs to be in place to protect the patient and guarantee that medications can be prescribed by their doctor for ongoing conditions. The medications need continued coverage if the patient has been on them during the previous and current year. Patients can reach out to advocacy groups to seek information on what legislation is enacted in their state. Let my Doctors Decide is a national partnership of leaders across health care working in support of a simple goal; treatment decisions should be made by patients and trusted health care professionals, not insurance companies or pharmacy benefit mangers reports letmydoctorsdecide.org . Finally, the patient’s insurance companies have an appeals process in place for patients whose medications are no longer covered. 

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References:

https://www.keepmyrx.org/issues/non-medical-switching/

What Is the Difference Between White, Brown, and Clear Bagging?

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What Is the Difference Between White, Brown, and Clear Bagging? from Patient Empowerment Network on Vimeo.

White, brown and clear bagging all refer to the days ways in which specialty medications can be delivered. Watch as Joanna Morales, Esq, CEO of Triage Cancer explains the differences and shares more about the new standard of gold bagging.

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Transcript

Diahanna Vallentine:  

Could you break down the difference between white… We’re gonna switch gears a little bit between white, brown and clear bagging? I had never heard these terms before. 

Joanna Morales:  

Yeah, so bagging actually refers to the way that specialty drugs are being delivered to a patient, and brown bagging, it’s kind of like the idea of brown bag in your lunch, where you’re bringing your own lunch to work or to school. So brown bagging is where the patients are getting the drugs from their specialty pharmacy, and then they’re bringing them to their healthcare provider where the drugs are going to be prepared and where the patient is actually going to take them, like in a chemotherapy clinic. Brown bagging as a process has pretty much been banned and isn’t really used, but white bagging is when a specialty pharmacy actually ships the drugs to where the patient is going to take that, so if they’re going to a hospital, the specialty pharmacy will send the drugs to the hospital. Clear bagging is where the healthcare system where the patient is getting care, they have their own specialty pharmacy in-house, and that specialty pharmacy is delivering the drugs to where the patient is actually going to take them. So, if we’re talking about a larger healthcare system, you might have the specialty pharmacy in another part of the state, but is sending it internally in its health care system to the patient-specific hospital. 

 So that’s clear bagging. There is a new process called gold bagging, which the industry is really referring to it as the gold standard in an ideal world, this would be the best way for patients to get access to their drugs where the specialty pharmacy is actually located in the same building, really, of where the patient is going to get care, so that there is fewer steps in the process of where the drug is being prepared to where the patient is actually taking the drug, and so it also… Again, in an ideal world, all of that’s happening with patient safety in mind and a lack of mistakes and is even timed to the patient’s appointment of time, and so that’s why they refer to it as gold-bagging because it would be the gold standard of care.

What is the Difference Between an Internal and External Appeal?

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What Is the Difference Between an Internal and External Appeal? from Patient Empowerment Network on Vimeo.

 Joanna Morales, Esq, CEO of Triage Cancer explains the difference between an internal and external appeal and encourages patients to appeal if they ever need. She shares that only .2% of claims were appealed in 2019 out of more than 40 million.  

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Transcript

Diahanna Vallentine:

What is the difference between an internal appeal and an external appeal? 

Joanna Morales: So, the process for appealing depends on the type of health insurance plan that you have, but if you have an individual health insurance plan or you get a health insurance plan through your employer, an internal appeal is when you go back to the insurance company and you ask them to reconsider. So it’s internal to the insurance company and asking them to take another look to see if they’ll cover your care, but as a result of the Affordable Care Act, every state now also requires those insurance companies to provide access to an external appeal, where you get to go outside of the insurance company to an independent entity, and they’re going to take a look to see whether or not the care that’s been prescribed to you is medically necessary. And if they decide that it is, that decision is binding on the insurance company, which means that the insurance company is going to have to cover that care, and we know that about 50% of the time on average across the country, external appeals are successful for patients. Unfortunately, very few patients actually go through the appeals process, we know based on the data that in 2019, just looking at market place plans, more than 40 million claims were denied, but only .2% of those claims were appealed and not even to the external appeals level, just through the internal appeals process. So, when you think about 50% of the time external appeals are successful, when we’re talking about 40 million claims, we could estimate that 20 million of those claims were patients who either didn’t get the care that they were prescribed by their healthcare team because they couldn’t afford to pay for it out of pocket or they paid for it out of pocket. And when we’re talking about the financial burden of a cancer diagnosis, not appealing, those denials is certainly contributing to that financial burden, and so we want people to understand their rights to appeal. 

Diahanna Vallentine:

Can we go back really quickly to the appeal process, have a quick question, So every state then has an external appeal program, will every patient get notification that they can go outside of the internal appeal process, would they know that? 

Joanna Morales:

Part of the law’s requirements when a patient is sent a denial letter from the insurance company, that denial has to include the information on how to actually go through the external appeals process, so there is a notice requirement. Now, you have to be savvy as a consumer because that notice might be in small print or on the back side of the letter, but most insurance companies do provide this notice, but patients still need to make sure that they’re following the insurance company’s rules for how to access the appeals process, and that includes following the deadlines. And unfortunately, I think when patients are getting a lot of mail from insurance companies and bills from their providers, there’s a tendency to avoid dealing with those bills for a while, and that the mail can pile up, but it’s important to actually open your mail because there might be key deadlines that you’re missing, if you’re putting off reviewing those bills.

How to Effectively Approach the Prior Authorization Process

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How to Effectively Approach the Prior Authorization Process from Patient Empowerment Network on Vimeo.

The prior authorization process can be a daunting one and often time-consuming. Joanna Morales, Esq, CEO of Triage Cancer shares how to make this process easier for patients and their loved ones and explains the appeal process you’d go through if your prior authorizations ever were denied.  

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Transcript

Diahanna Vallentine:

So prior authorizations can be time-consuming and lead to delays in treatment, is there any way for patients and their loved ones to speed up the process of getting this taken care of? 

Joanna Morales: I think being proactive, unfortunately, it puts one more things on the patient to have to do to get access to care, but proactively having conversations with your healthcare team to see if they’re going to fill out the prior authorization or if it’s something that you need to do, or if you need to contact the insurance company and find out if you actually need the prior authorization. So, if you’re proactive and you’re communicating effectively with your healthcare team and the insurance company, it will speed up the process to get access to that prior authorization. 

Diahanna Vallentine:

So, let’s just say you did all of that, and then you come back and that prior authorization for that treatment is denied. What can you do when the insurance company denies coverage for your care? 

Joanna Morales:

Well, it’s definitely important that people don’t take no for an answer, and unfortunately most people do. We kind of assume that insurance companies are accurate when they tell us that they’re not going to cover something, but we have the right to appeal that decision, and if we actually appeal these decisions, we are much more likely to get access to the care that is being prescribed to us by our healthcare team.  

Diahanna Vallentine:

Was there any other things when it goes to prior authorizations that patients should know that helps speed things up, whether it’s working through their treatment team, or can they request a particular person to talk to on the phone when they call their insurance companies that may help? 

Joanna Morales:

I think when dealing with prior authorizations, patients can be proactive in communicating with their insurance company about the care that they’re going to receive, and that can include asking if there is a list of when a prior authorization is required for different types of medical care, but you could also potentially ask if there is a case manager at your insurance company who could be your recurring point of contact at the insurance company to help guide you through the treatment that you’re receiving and their coverage of that treatment. But it is important to realize that that case manager works for the insurance company, they don’t work for you, they can be very helpful in providing pieces of information, but it is important just to keep in mind that your case manager might be providing information, but you might still get denied for the care that you’re receiving, and then to know what your rights are with respect to appeals can be really useful.  

Diahanna Vallentine:

Okay, so once you go through the external appeal and the general appeal is denied, can you still appeal that or is that a final decision? 

Joanna Morales:

Generally, and every state’s rules are slightly different once you’ve received a denial in the external appeals process, that is the final say. Some insurance companies have multiple levels of internal appeals before you get to an external appeal, so usually once the external appeal has been decided, that’s the final decision.

What Are Prior Authorizations?

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What Are Prior Authorizations? from Patient Empowerment Network on Vimeo.

Prior authorizations are another big issue many patients may encounter. Joanna Morales, Esq, CEO of Triage Cancer describes what a prior authorization is.  

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Transcript

Diahanna Vallentine:

Let’s go into prior authorizations, that’s another big issue, that patients have…What are prior authorizations?   

Joanna Morales:

So prior authorizations are a requirement that an insurance company wants you to get permission from them before you actually get any medical care or get access to a prescription drug, and prior authorizations can be called different things, so they might be called prior auths or pre-authorizations or pre-auths, so if you hear these terms, they mean the same thing, but unfortunately, most interns company is don’t give you a list of the things you need to get prior authorizations for. So, you always have to be proactive as a patient and ask your insurance company if you need a prior authorization for any of the medical care that you’re going to receive, now, if you happen to be getting care at a larger hospital, your healthcare team might actually be submitting the prior authorizations for you, but it’s still your responsibility as the consumer and the patient to be checking if you need that prior authorization because if you don’t, and your healthcare team fails to get the prior authorization, if you get that medical care, then your insurance company could come back and say, we’re not covering that care because you didn’t get the prior authorization. So, it’s always important to proactively find out if you need the prior authorization before you get any care.

The Controversial Conundrum of Co-Pay Accumulators And What to Do About It

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Prescription medications can be super expensive so, it’s a good thing that there are assistance programs available to help patients cover some of the costs. Assistance is often provided by charities, nonprofits, or drug manufacturers, and is designed to offset the cost of treatments and medications. The only catch is that there are now other programs in place that seem to negate any of the benefits that the assistance programs provide. 

If it sounds confusing, that’s because it kind of is, but the simplest explanation is this: Pharmaceutical companies, and other organizations, often offer programs to offset the high cost of medications. The programs are known as copay assistance programs, or sometimes coupon programs or copay savings programs. Manufacturers or charitable organizations can cover part of the cost of medications, relieving patients of some of the burden of meeting the cost of their copays and annual maximum out-of-pocket expenses. The assistance provided is capped at a maximum amount, and any contributions the assistance programs make to the cost of the medications can be applied to the patient’s deductible and out-of-pocket expenses until the maximum amount is reached. 

However, in 2018, in response to the copay assistance programs, insurance companies and pharmacy benefit managers (PBMs) created copay accumulator programs. The copay accumulator programs still allow patients to get assistance from the drug manufacturers or other groups, but they prohibit that assistance from being applied toward a patient’s deductible or annual maximum out-of-pocket expenses. So, once a patient uses up any assistance, the patient is still responsible for their entire copay and maximum out-of-pocket expenses before their full insurance benefits kick in. Patients with a high deductible, or a separate pharmacy deductible, could end up paying more over time because it will take them longer to meet their deductible and receive full insurance benefits. 

There are also similar programs known as copay maximizer programs in which the copay assistance maximum amount is applied evenly throughout the year, but still doesn’t count toward the patient’s deductible and out-of-pocket maximum. In the copay maximizer programs, the amount the patient has to pay is more balanced over the year, but it does not lower the overall amount the patient is responsible for paying. 

Since arriving on the scene, the copay accumulator programs have been controversial. Patient advocacy organizations say the accumulator programs are unfair. Organizations such as the Immune Deficiency Foundation (IDF) have noted that it doesn’t make sense that the source of the payment for the medication should matter. If medications are paid for by the patient, the payment counts toward the deductible, but if the medications are paid for by someone else, the payment doesn’t count toward the deductible. Therefore, insurance providers are effectively collecting the deductibles and out-of-pocket maximums twice. In January 2021, the American Society of Clinical Oncology (ASCO) released a position statement regarding copay accumulators and copay maximizers. The ASCO is opposed to the programs and calls them harmful. 

On the other hand, PBMs and insurance providers say that copay accumulator programs are beneficial because they encourage patients to choose lower cost drug options. They argue that it is the copay assistance programs that are unfair because they encourage patients to use more expensive brand-name drugs instead of generics or lower cost brands, which increases premiums. In addition, they claim that, rather than actually reducing the cost of the medications, assistance programs transfer the cost of the medications onto the PBMs and insurance providers, which also leads to increased premiums. 

Either way, it is the patients who are most affected, and some see copay accumulators as blatant discrimination against people with chronic and complex illnesses, such as cancer, because they don’t often have a choice for generic or lower cost medications. These patients rely on specialty brand prescriptions for treatment and recovery. Many also have high deductibles or are required to pay a percentage of the prescription cost rather than a flat amount.  

Studies indicate that the result of copay accumulator programs is poorer health outcomes and possible higher costs to the healthcare system. The extra costs often prevent patients from using specialty therapies or following the doctor recommended treatments. More than one in four specialty brand prescriptions are no longer filled when patients have to pay toward their deductibles for them. One study found that patients who have health savings accounts with an accumulator program for autoimmune drugs filled their prescriptions less often and were more likely to discontinue their prescriptions. Another study found that higher prescription copayments meant that patients, especially older women, were less likely to take their medications as prescribed. Failure to follow treatment as prescribed could be potentially life-threatening for many patients with cancer and other complex illnesses.   

Initially there was a restriction on copay accumulator programs. They could only be used for medications that also had a generic version, but in May 2020 the Centers for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services ruled that insurance companies could use the copay accumulator programs without any restrictions. The issue is not settled with CMS and more rulings about copay accumulators are expected. Organizations like the ASCO recommend that CMS should ban the use of the accumulator programs and that federal and state governments should pass legislation banning them as well. They further recommend that insurance companies and PBMs should discontinue the copay accumulator programs.  

IDF is one of the organizations that is trying to ban copay accumulators at the state and federal level. As of spring 2022 Arizona, Arkansas, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Nebraska, North Carolina, Ohio, Oklahoma, Tennessee, Virginia, Washington, West Virginia, and Puerto Rico have passed legislation banning copay accumulators.  

In addition to legislation at the state level, federal help may be on the way. In November 2021, a bipartisan group of congressional representatives introduced H.R. 5801, the Help Ensure Lower Patient (HELP) Copays Act. Part of the bill ensures that copay assistance gets applied toward deductibles or out-of-pocket maximums. However, the last action on the bill was also in November 2021 when it was referred to the subcommittee on health.  

While waiting for the laws to catch up with the implementation of the copay accumulator programs, there are things patients can do to protect themselves from high out-of-pocket expenses. Most importantly, patients need to be aware of copay accumulators, and use that awareness to carefully read their insurance plans before enrolling. It can be difficult to determine if the insurance plans contain copay accumulator programs because the language is often unclear and can lack transparency. The name is confusing, copay accumulator doesn’t exactly describe what the program is, and each provider uses their own name for the programs. Other names include: Out-of-Pocket Protection Program (Express Scripts), True Accumulation (Caremark), and Coupon Adjustment: Benefit Plan Protection Program (United Healthcare). Copay accumulator programs have also been implemented in the middle of a plan year, without notification, so many patients don’t know they have one until they get stuck with a large bill. The best way to find out if a plan contains a copay accumulator or maximizer program is to call the insurance provider’s customer service number and ask them directly. Be sure to specifically ask whether or not the plan prohibits third party (manufacturer, charity, or nonprofit) contributions from counting toward the deductible and out-of-pocket costs.  

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Sources: 

Brooks, Amanda. “Copay Accumulator Programs: What Patients Should Know.” GoodRX Health, June 18, 2020, https://www.goodrx.com/insurance/health-insurance/copay-accumulator-programs-cms-ruling. Accessed May 10, 2022. 

Fein, Adam J. “Copay Accumulators: Costly Consequences of a New Cost-Shifting Pharmacy Benefit.” Drug Channels, January 3, 2018, https://www.drugchannels.net/2018/05/copay-accumulators-costly-consequences.html. Accessed May 8, 2022. 

“American Society of Clinical Oncology Position Statement: Copay Accumulators and Copay Maximizers.” asco.org, January 21, 2021, https://www.asco.org/sites/new-www.asco.org/files/content-files/advocacy-and-policy/documents/2021-CopayAccumulatorsStatement.pdf. Accessed May 10, 2022. 

Immune Deficiency Foundation. “Support the HELP Copays Act and Fight Unfair Copay Accumulators.” primaryimmune.org, December 2, 2021, https://primaryimmune.org/news/support-help-copays-act-and-fight-unfair-copay-accumulators. Accessed May 9, 2022. 

National Conference of State Legislators. “Copayment Adjustment Programs.” ncsl.org, April 4, 2022, https://www.ncsl.org/research/health/copayment-adjustment-programs.aspx#State. Accessed May 11, 2022. 

What is a Co-Pay Accumulator Program?

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What Is a Co-Pay Accumulator Program? from Patient Empowerment Network on Vimeo.

Joanna Morales, Esq, CEO of Triage Cancer describes a co-pay accumulator program and shares some states may have protections against such programs.

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Transcript

Diahanna Vallentine:

So, Joanna. What is a co-pay accumulator program? I’ve had patients ask me this question. 

Joanna Morales:

So, a co-pay accumulator program is a program that insurance companies actually use to exclude the financial health that you’re getting to cover your out-of-pocket costs from counting against your deductibles or your out-of-pocket maximum. So this can actually be a huge problem for patients because it greatly increases their out-of-pocket costs. So imagine that you have an out-of-pocket maximum on your plan of $5000, and you have a prescription that costs $5000 for one month, which isn’t unheard of when we’re talking about the cost of cancer care, but you are able to actually get financial help to pay for $3000 of that cost, normally that financial help, which still counts towards your out-of-pocket maximum, so that would mean that you’ve met your out-of-pocket maximum of $5000 for the whole year. So you shouldn’t have to pay any other medical expenses out-of-pocket for the rest of that plan year, but with accumulator programs, the $3000 that you got financial help lift no longer count against your out-of-pocket maximum, and you actually have to face paying that $3000 in out-of-pocket expenses that you will have to pay during the year, so having to pay those additional costs out-of-pocket could greatly increase costs for patients and could potentially drive patients into debt or force them to stop taking their medications because they can’t afford to pay those out-of-pocket costs. Even though these co-pay accumulator programs are becoming more widespread, there are about 12 states now that have some protections around health insurance companies using co-pay accumulators, so this is actually an advocacy opportunity for the cancer community to take a look at how co-pay accumulators are being used by insurance companies. 

Diahanna Vallentine:

So, when a state gives people opportunities to participate that going against their deductibles or their co-pays, then that person no longer has to worry about their insurance if they change insurance or the next year, ’cause all the insurance companies would be going by that law, that state law? 

Joanna Morales:

Every state law is slightly different in how they handle copay accumulators, but generally, there are protections for consumers, so that insurance companies aren’t using copay accumulator programs to increase out-of-pocket cost for patients.

How Do Insurance Companies Cover Prescription Drugs?

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How Do Insurance Companies Cover Prescription Drugs? from Patient Empowerment Network on Vimeo.

Joanna Morales, Esq, CEO of Triage Cancer shares how insurance companies cover prescription drugs and discusses financial assistant programs to help with out-of-pocket costs.  

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Transcript

Diahanna Vallentine:

So, Joanna we’re going to talk about co-pay accumulators. Can you tell me how do insurance companies cover prescription drugs? 

Joanna Morales:

Most insurance companies do provide coverage for prescription drugs, but you may still have costs that you have to pay out of pocket when you get a prescription, so first you might have to pay a deductible and that deductible could be specific to your prescription drugs, so maybe you have a $300 deductible for prescription drugs, where you have to pay that amount first before your health insurance coverage kicks in to pay for your prescription drugs, and then you might also have to pay co-payments when you go and pick up your prescription. So, if you’re going to go and pick up an antibiotic, for example, you might only have a $5 co-payment, but if you’re going to pick up a more expensive drug, you might have a $300 co-payment, and co-payments are different from co insurance and cost share amounts and those are two terms that are used in the same way. So it’s a percentage, it’s the difference between what insurance companies will pay for our medical care and what we pay, and more expensive prescription drugs, like specialty drugs, like cancer drugs, are actually paid for using that co-insurance model rather than a co-payment model. 

So, an insurance company is more likely to charge you a co-insurance amount to get those more expensive drugs, so you might be paying 20% or even 30% of those drugs rather than that flat feet co-payment amount. And then you also have an out-of-pocket maximum, and that out-of-pocket maximum is a fixed dollar amount where it’s the most that you’re going to pay out of pocket for your medical expenses during the year. Some insurance companies include prescription drugs in the main out-of-pocket maximum, and some plans carve out prescription drugs and that they have their own out-of-pocket maximum. So, it’s very important for people to understand how their insurance plan treats their coverage of prescription drugs and understand what they’re going to have to pay out of pocket for their prescription drugs. 

Diahanna Vallentine:

Okay, with that. So, when a person looks at the total cost of their drugs, how it’s going to work every year, so the cost, they need to take into a consideration which programs they can get grants, it’s what they considered grants? 

Joanna Morales:

Yeah, so any of the potential out-of-pocket costs that someone might have to pay, there are financial assistance programs out there to help pay for those out-of-pocket costs, so some provide assistance with the co-payments, some will go towards your deductibles or even your out-of-pocket maximums, and there are lots of different types of prescription drug assistance programs, so some come from private organizations, some are specific to the cancer community, most pharmaceutical companies that make the drugs also have co-pay assistance programs. So, there are lots of places to go to look for financial assistance to help pay for those out-of-pocket costs, but what’s important to realize is that if you’re getting help paying for those out-of-pocket costs from one of those financial assistance programs, the amount of money that you’re getting assistance for to pay those costs still counts towards your deductible or your out-of-pocket maximum. So, if you have $500 in a deductible and you get $500 of financial assistance to pay that deductible, it still counts towards your deductible, so you’re not being penalized for actually getting that financial assistance, it helps towards your total out of pocket costs that you’re spending.