Each patient may have a different insurance plan. In order to determine the insurance benefit for any patient, a completed Prescription Start Form (PSF) must be signed and submitted to PTC CaresTM. This form is available in our Resource Library.
After the PSF is submitted, your PTC Cares team will work with your insurance plan on your behalf to verify your insurance benefits.
Insurance providers may require more information from your physician about medical necessity of PTC products. Your PTC Cares team will work directly with your healthcare provider to submit information necessary to answer questions from your insurance provider. We expect this process with your insurance company to vary from days to several weeks, depending on your insurance plan and the information requested from the insurer.
The length of time the prescription is active will vary by insurance provider. Most insurance providers authorize prescriptions for 6 months to 1 year. Your PTC Cares case manager will monitor your prescription and will apply for reauthorization before the prescription expires.
Not everyone will have the same insurance plan. The specific benefits of that plan determine the amount paid by your insurance provider and the amount that is your responsibility.
In order to determine the insurance benefits for any patient, a completed Prescription Start Form must be submitted to PTC Cares.
At that point, your PTC Cares team will work with your insurance plan on your behalf to verify your insurance benefit to determine coverage, including any cost assigned to the patient. The type of out-of-pocket expenses may include a copay, coinsurance, and/or deductible.
PTC has created comprehensive Patient Support Services to provide you with information on financial support needed to help support access to your PTC product.
Your PTC Cares case manager will determine which Patient Support Services are right for you, based on your type of insurance and eligibility requirements.
Private or Commercial Insurance
If you have private or commercial insurance, your PTC Cares case manager will automatically enroll you into a program that will eliminate your costs, in most cases. Some state regulations mandate a patient pay a small amount (such as $10) each month. In those cases, patients may have a small monthly payment.
Public or Government Insurance
If your insurance is provided by the government (like Medicaid or Medicare), you may have to pay a certain amount out-of-pocket. In these cases, your PTC Cares case manager may refer you to a third-party patient foundation that will work with you to provide financial assistance based on your eligibility.
Patients whose insurance denies coverage or who have no insurance are eligible to apply for our free drug program. This program has eligibility requirements and requires an application.
REMEMBER: In order for your PTC Cares case manager to help, a completed Prescription Start Form must be signed and submitted to PTC Cares. The form can be found in our Resource Library.
While it is impossible for us to predict what factors influence healthcare premiums, it is not expected that premiums for prescription coverage will increase due to the use of PTC products.
PTC has the EMFLAZA Bridge Program in place to temporarily provide PTC products to anyone previously receiving a PTC therapy until they receive insurance decision. Under the EMFLAZA Bridge Program, patients will receive their PTC product free of charge while they are waiting for insurance decision.
REMEMBER: To get started, make sure that both you and your healthcare provider sign the PSF and submit the form to PTC Cares. This form is available in our Resource Library.
Your PTC Cares case manager will keep you informed of the progress of your application. You may call 1-844-4PTC-CARES (1-844-478-2227) for an update 8 AM – 8 PM EST, Monday – Friday.
Once approved for your PTC products, the PTC Cares contracted pharmacy will call you to arrange delivery. Your prescription will be delivered to your home, office, or other location of your choice. They will also call you each month to manage your refills and confirm delivery prior to shipments.
Generally, insurance companies authorize shipments of a 30-day supply. However, some insurers may approve a 90-day supply. You may discuss the shipment approved by your insurance company with your PTC Cares case manager.
The PTC Cares pharmacy will call you to schedule your refill. You can also call 1-844-4PTC-CARES (1-844-478-2227) if you have any questions about your refills.
If you choose not to sign the PSF and enroll in PTC Cares, your prescription will go directly to the PTC Cares contracted pharmacy. The pharmacy will determine your insurance coverage but will not be able to help you with appeals if coverage is denied. They will not be able to enroll you in any of the customized service and financial assistance programs PTC has in place to support you during your treatment after you receive your product.
More information about PTC Cares or PTC products can be found on PTCCares.com. Case managers are able to assist you and can be contacted at 1-844-4PTC-CARES (1-844-478-2227). They are available 8 AM – 8 PM EST, Monday – Friday.