The copayment assistance program is now open!
| Click HERE for the application packet Version 15.1 (Updated 2/3/2024) |
Click HERE for the Claim Form Version 15.1 (Updated 2/3/2024) |
Please use our program as a last resort - try the manufacture's program first then use us if you still need help!
The Brain Tumor Drug Copayment Assistance Program, a program of the Musella Foundation For Brain Tumor Research & Information, Inc., provides financial assistance to families who need help covering the cost of certain drugs used to treat Primary Malignant Brain Tumors (Grade 3 or 4). There is no fee for this assistance, and you will not be obligated to pay it back in any way. We will never tell you which treatment to use, which doctor to use or which pharmacy to use! Although insurance is required to apply to this program, we DO cover you if you use pharmacies that do not accept your insurance - so you can shop around and use the pharmacies that charge less than your copay! Covered Treatments include (brand name, generics or bioequivalents of these treatments):
The Program's resources are limited, but we will help as many families as possible. We will give awards on a first come first served basis until the funds run out - so apply now. There is a yearly maximum per person of $5,000. When approved, we can go back 3 months to reimburse you for any of the covered treatments you already paid for.
This program is designed to help people who:
- Have a glioblastoma multiforme, or other type of PRIMARY (NOT METASTATIC) MALIGNANT BRAIN TUMORS (Grade 3 or 4) (Such as Anaplastic Astrocytoma, Gliosarcoma, High Grade Oligodendroglioma, DIPG (Diffuse Intrinsic Pontine Glioma), DMG (Diffuse Midline Glioma) Etc), and who use one or more of the drugs covered by the program
- Have insurance that usually pays for or allows toward deductible charges for the desired treatment.
- Are residents of the USA
- Have income that is not more than shown on the chart below! If you are slightly above but have special circumstances like can not work, send a note telling us why and how much you think you will make this year, and we will consider it.
| Updated 2/3/2024 From the tax form use the line that says "TOTAL INCOME". |
|
|---|---|
| # of People in Family | Max Family Income |
| 1 | $75,300 |
| 2 | $102,200 |
| 3 | $129,100 |
| 4 | $156,000 |
| 5 | $182,900 |
| 6 | $209,800 |
| 7 (or more) | $236,700 |
If you do not meet these qualifications but are having trouble paying for drugs to treat your brain tumor, you may be able to receive financial assistance from other organizations. See a list of resources here.
How to apply (first time):
- Click on the Application Packet link above. Fill out the form by typing into it on your computer, then print it out, sign it and gather the following documents. Then bring it to your doctor's office, let them fill out the certification form and ask if they can upload or fax the entire packet back to us. That is the fastest way!
- If you can scan the documents and combine them into one PDF file, you can upload it using our contact form.
- Do NOT email or mail any paperwork to us. It will add a few days to the processing time, which may cause you to miss out if our program closes in that time period. Best is uploading, then fax to our main fax number. If you can't do either one, then fax to our alternate fax - which will also add a few days. PDF is our preferred format, but we can accept JPG, GIF, Png and JPEG files. If you have an Iphone you can scan documents to PDF by following these directions.
- Alternate Contact Person: We require a second contact person that you allow us to talk to in case we can't contact the patient. It is best if it is a relative, caregiver or friend of the patient. As a last resort - if none are available, it can be the patient advocate.
- Proof of Diagnosis of a Glioblastoma Multiforme or other primary malignant glioma, (Grade 3 or 4 only) by having your doctor fill out and sign the "Doctor's Certification Form" - OR - a copy of your pathology report!
- Special Circumstances: If you qualify - leave this blank. Only use it when your income is higher than our maximum allowed income to explain if you have a decrease in income since the tax filing. Explain why you would make less this year. You can include a separate page of paper if more space is needed. Tell us how much you think you will make this year and send whatever proof you may have.
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Note: Due to advice from our auditors, we had to crack down on what proof is allowed for income. Please read this next section!
Proof of Income Copy of the first 2 pages of your most recent tax return (black out the first 5 numbers of your social security number) is best and will result in the quickest decision and best chance for approval. If you did not file taxes, send a signed letter saying you did not file taxes in the last 3 years and why, and tell us what your income is, how many people are in your family, and include proof of that income in some other way. Note that Social Security Benefits letters, bank statements and W2 Forms by themselves are not sufficient because there may be other sources of income. - Proof of Insurance that covers the type of treatment you are applying for (Copy of your insurance card is best, but if not available a printout from pharmacy or doctor showing insurance information is usually acceptable.).
- Note - we DO accept electronic signatures to make it easy for you.
How to file a claim: (You can send at same time as application or wait until you get an approval of the grant)
- We do NOT do electronic billing - you must use our claim form and send by fax or upload it as a PDF document using our Contact Form. Uploads are preferred. If you can not upload or fax, you can mail it to us.
- Use the claim form above - click on CLAIM FORM (it is also in the application packet).
- We can NOT pay until the medication is dispensed.
- Get a detailed receipt or explanation of benefits that must show: Patient Name, Date Dispensed, Treatment Name and Patient Responsibility. The charges and amount insurance paid are optional.
- You tell us on the claim form if we should pay the patient or the pharmacy / provider. We can pay either the pharmacy or the patient - whichever is easier for you. Most of the time we pay the pharmacy directly.
- DO NOT SEND a 1500 CLAIM FORM. We can not use those. Use our claim form!
- Use a separate claim line for each capsule size if you were charged for multiple capsule sizes. We must match up the exact number from the receipt on the claim form, which won't happen if you lump multiple capsule sizes together. If there are multiple claims for the same date of service, they have to be submitted on the same claim form, otherwise the first claim will be paid and subsequent claims will be denied as duplicates!
- Use the dispensed date from the receipt as the date dispensed on the claim form even if you actually received it a few days later - again - we must match up what you put on the claim form with the receipt.
- The Claim Form asks for the date of birth and the last 4 digits of the social security number. You only have to enter at least one of these, in case we have a patient with the same name!
- Note that claims must be submitted within 1 month after the end date of your grant, and unused funds will be returned to our copayment assistance fund and used to help other brain tumor patients. IF you need more time to file a claim, contact us before the 1 month period is up.
- The pharmacy is going to ask for electronic billing details like "Bin number, PCN, GRP". Tell them "The Musella Foundation does NOT do electronic billing so we do not have those electronic billing details. See above on how to file paper claim!
How to apply for renewal of grant:
When your grant expires, you may apply for a renewal of the grant by sending in the same application as for a new grant - but you do not need to have the doctor sign the certification form. Just write on it "on file". You need to send proof of income and insurance again. Note that you can't apply until the old grant expires. The new grant can not look back prior to the expiration date of the old grant. For example, if you used up the funds in the first grant and reapply, we can't go back and pay claims from before the first expiration date. Also note that when you apply for a renewal, we have to close out the old grant and take any remaining funds back to reuse on other grants. So if there are any unpaid claims from the old grant, send them along with the application for renewal. If the renewal application is approved before we receive a claim from the old grant, these claims may be processed from the new grant, so tell us if you think there may be more claims coming when you apply!
We encourage you to apply to all of the other sources of assistance first, and use us as a last resort as we have limited funds.
Complete applications are considered in the order in which they are entered into our system. Sending in a partial application does not hold your place. Hand written applications are strongly discouraged - they take way too long to process and go back and forth to verify information. Some patients missed out on grants because the handwriting was not legible. The forms are designed to allow you to type directly into them. As the program opens and closes quickly, sending the application by uploading to the website instead of by email or mail or even fax, and typing the information, will save a few days and increase your chances of getting approved before the program closes. We can not accept applications when the program is closed - if we held them, the program could never open. At the end of every month, we go over expired grants and reclaim the funds so we might reopen for a few patients. You can contact us or even just send in an application on the first of each month even if the website says the program is closed.
Tips:
- The easiest way to apply: Click on the Application link above. The application will open on your computer. Fill out the form on your computer - just type into each field. Then print it and sign it. Gather the documents you need: insurance card and first 2 pages of your last tax return. Then bring the entire packet to your doctors office and ask them to fill out the "Certification Form For Physicians" and ask them to upload or fax the entire packet to us.
- If you do not have a scanner, you can take a picture of the documents and upload them directly from your phone!
- You can use your Pathology Report as proof of diagnosis instead of having the doctor sign the form!
To apply, click on the link for the application above and fax or mail it to us.
Call us at 1-855-426-2672 (toll free) if you have any questions.