Resources are available for cancer patients, and the specialty pharmacy provider can help guide patients to greater adherence and best fit. Here's a comprehensive guide to these programs and what they can provide.
Many patients on specialty drugs may experience large deductibles, increased out-of-pocket costs, and coverage changes that may affect their ability to afford their medications. As a specialty pharmacy provider, a key component of providing comprehensive care is reviewing a patient’s reimbursement situation and offering financial assistance options to those on high-cost medications.
Locating financial assistance is particularly important for patients receiving oral oncology therapy. A study conducted by Prime Therapeutics and presented at the Academy of Managed Care Pharmacy annual meeting in 2010 found that 1 in 6 patients with an oral oncology out-of-pocket expense of greater than $200 on their first claim abandoned therapy and were at least 3 times more likely to abandon their oral oncology therapy than patients with an out-of-pocket cost of $100 or less on the first claim. 1 Active searching for financial assistance programs by specialty pharmacy providers may help remove a patient’s financial barrier to filling their medication and may improve adherence and persistency on the therapy. Several different types of financial assistance programs are available:
*Copayment Assistance Programs: A copayment assistance program, also called a manufacturer copay card, may be available to patients who have prescription insurance. One of the most common forms of copayment assistance program may be offered in the form of a rebate, coupon, or copayment card directly from the manufacturer. These manufacturer programs are typically offered to all patients, are not usually need based, and do not usually require an application process. However, policies on whether or not these programs can be used in conjunction with a patient’s government-sponsored plan vary, and most do not include patients who receive Medicare, Medicaid, or Tricare, or residents of certain states, such as Massachusetts.
*Drug- or Company-Specific Patient Assistance Programs: Patient Assistance Programs (PAPs) are programs set up voluntarily by pharmaceutical companies to offer free or low-cost drugs to primarily uninsured patients who cannot afford their medication. Although each program has its own rules, patients must typically be US residents, have no prescription insurance, and be under 200% of the federal poverty level as certified by the physician or required documentation. Companies vary on whether or not they allow Medicare and other government-insured patients to enroll in these programs.
*Disease-Based Patient Assistance Programs: Another form of assistance is disease-based assistance, where funds are usually administered through a not-for-profit group that can evaluate a patient application based on financial need. These funds and foundations typically deal with medications and diseases that are expected to have significant out-of-pocket expenses (often thousands of dollars per month) associated with them. These programs can assist patients who are having a difficult time paying for the deductible, coinsurance, or copayments. Pharmaceutical companies often fund these programs, but are not involved in evaluating whether or not the patient meets the pre-specified program requirements.
Funding is variable and can be exhausted at any time. After monies are depleted, enrollment can be closed to new patients or the fund can be closed completely for existing patients as well. Additional funding may come at any time to reopen the fund, so it may be beneficial to recheck often.
Many times, disease-based assistance runs on a calendar year funding cycle, so there may be more funds available toward the first of the year. Sometimes additional monies are added to the fund monthly, so applying on the first of the month may increase the chance of successfully obtaining disease-based assistance.
As previously mentioned, many programs exclude patients with government-sponsored insurance, such as Medicare Part D. However, with high-cost medications, it is still worth searching for patient assistance. The disease-based patient assistance programs are most likely to be able to assist Part D members, so starting with those funds and foundations may lead to a qualifying program. If there are no disease-based programs available or the fund has been closed, visiting one of the resource Web sites, such as www.needymeds.org or www. pparx.org, will lead to the drug-specific programs where each program will set forth rules regarding Medicare Part D patient assistance.
There are groups that charge a fee to help a patient fill out an application for one of these programs. Please assure your patients that there is no charge to apply to these programs, and if a group is requesting funds in order to facilitate an application, the patient or pharmacy can contact the program directly via phone, Web, or e-mail or print out an application and fill it out with assistance from the physician’s office free of charge.
The Resources sidebar contains a compilation of Web sites that can be used by a specialty pharmacy provider to search for medication financial assistance. SPT
1. Starner CI, Gleason PP, Gunderson BW. Oral oncology prescription abandonment association with high out-of-pocket member expense. J Manag Care Pharm, 2010; 16(2): 161-162.
About the Author
Stacey Ness, PharmD, has worked in both national specialty pharmacy and payer organizations and has experience in clinical management, adherence and persistency programs, as well as chronic disease cost optimization strategies. Dr. Ness is active in the Consortium of Multiple Sclerosis Centers, Academy of Managed Care Pharmacy, National Home Infusion Association, and Hematology and Oncology Pharmacy Association, and has served on the Minnesota Medicaid Drug Formulary Committee since 2008. She is currently associate director of Specialty Services at Managed Health Care Associates, Inc, a health care services organization based in Florham Park, New Jersey. The views expressed in this article are those of the author alone and not of Managed Health Care Associates, Inc. The author and MHA disclaim any and all responsibility and liability with respect to this information and its use.
Cancer Care Foundation, www.cancercarecopay.org
Chronic Disease Fund (CDF), www.cdfund.org
Healthwell Foundation, www.healthwellfoundation.org
Leukemia and Lymphoma Society, www.leukemia-lymphoma.org
National Organization for Rare Disorders (NORD), www.rarediseases.org
Needy Meds, www.needymeds.org
Patient Access Network Foundation, www.panfoundation.org
Patient Assistance.com, www.patientassistance.com
Patient Services Incorporated, www.uneedpsi.org
Partnership for Prescription Assistance, www.pparxorg
Rx Assist, www.rxassist.org