Here are answers to some of the questions we’re asked most often. Need more details? Your Case Manager can help.
Will my insurance cover PTC products?
Each patient may have a different insurance plan and different coverage benefits. In order to determine the insurance benefit for any patient, a completed Prescription Start Form (PSF) must be signed and submitted by you and your provider to PTC CaresTM. This form is available in our Resource Library. After the PSF is submitted, your PTC Cares Case Manager will work with your insurance company on your behalf to verify your insurance benefits. Insurance companies may require more information from your healthcare provider about the medical necessity of PTC products. We will work directly with your healthcare provider to submit information necessary to answer questions from your insurance company. We expect this process to take from a few days to several weeks, depending on your insurance plan, the information requested from the insurer, and how quickly we can obtain the requested information from your healthcare provider.
After insurance coverage is approved, how long will the prescription continue?
The length of time the prescription is active will vary by insurance plan. Most insurance plans authorize prescriptions for 6 months to 1 year. Your PTC Cares Case Manager will monitor your prescription and will work with your physician and insurance to reauthorize treatment before the prescription expires to help make sure you have uninterrupted access to your medication.
How do I find out the status of my approval?
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 – 6 PM ET, Monday - Friday. Any messages left after regular hours will be returned the next business day.
How much will I have to pay for my prescription?
Not everyone will have the same insurance plan. The specific benefits of your plan determines the amount paid by your insurance company and the amount that is your responsibility. In order to determine the insurance benefits for any patient, a completed and signed Prescription Start Form must be submitted to PTC Cares by your physician. At that point, your Case Manager will work with your insurance company on your behalf to verify your insurance benefit to determine coverage, including any cost assigned to you. Out-of-pocket expenses may include a copay, coinsurance, and/or a 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 on eligibility requirements.
REMEMBER: You must sign the Prescription Start Form or Patient Consent Form to be eligible for PTC Cares Patient Support Services.
How can I minimize or eliminate out-of-pocket expenses?
Private or Commercial Insurance:
If you have private or commercial insurance, your PTC Cares Case Manager will automatically enroll you in a program that can eliminate your out-of-pocket 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 government-provided (such as Medicaid or Medicare), you may have to pay a certain amount out-of-pocket. In these cases, your PTC Cares Case Manager can provide more information about third-party patient foundations that will work with you to provide financial assistance based on your eligibility.
Patients whose insurance denies coverage or who have no insurance may be eligible to apply for our Patient Assistance 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, including the consent page, must be signed and submitted to PTC Cares. The form can be found in our Resource Library.
What happens if my access is interrupted due to insurance coverage issues?
Consented patients who are actively enrolled in PTC Cares can receive a temporary supply of PTC product free of charge while their Case Manager and physician work together to pursue an insurance decision. PTC has the Bridge Program in place to temporarily provide PTC products to anyone currently receiving a PTC therapy until they receive an insurance decision. Under the Bridge Program, active patients will temporarily receive their PTC product free of charge while they are waiting for an 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.
Will getting insurance coverage of any PTC product cause my insurance premiums to rise?
Although it is impossible for us to predict what factors may influence healthcare premiums, it is not expected that premiums for prescription coverage will increase due to the use of PTC products.
How will I get my PTC products?
Once you are approved for your PTC product, a PTC Cares contracted specialty pharmacy will call you to arrange delivery of your prescription to your home, office, or other location of your choice. They will then call you each month on an ongoing basis to manage and confirm delivery of each refill. Specialty pharmacies cannot ship your medication without confirmation from you. Therefore, it is very important to answer these calls in order to receive your medication on time.
How many days of therapy will be shipped to me?
Generally, insurance companies authorize shipments of a 30-day supply. However, some insurers may approve up to a 90-day supply. You may discuss the shipment approved by your insurance company with your PTC Cares Case Manager, or call the insurance company directly to verify their policy.
The PTC Cares specialty pharmacy will call you to schedule your refill about a week before you need it. You can also call 1-844-4PTC-CARES (1-844-478-2227) Monday – Friday, 8 AM – 6 PM ET if you have questions about your refills. Any messages left after regular hours will be returned the next business day.
What if I don’t want the services of PTC Cares?
If you choose not to sign the Prescription Start Form and enroll in PTC Cares, your prescription will go directly to one of our PTC Cares contracted pharmacies. The pharmacy will determine your insurance coverage but will not be able to help you with appeals if your coverage is denied. They also 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.