Helping Patients Pay for Medications An Algorithmic Approach

Helping Patients Pay for Medications: An Algorithmic Approach Tom Lynch, Pharm. D. Department of Family and Community Medicine Eastern Virginia Medical School Norfolk, VA

Outline l l l Patient Assistant Programs Drug Discount Card Programs Generic Drug Discount Programs Medicare Part D Drug Benefit How to Delay a Dunking in the Doughnut Hole Algorithm for Selecting Right Program for Your Patient

Effect of Medication Costs on Patient Adherence l l l 11% of diabetes patients take less oral medication than prescribed because of cost 1 20% of adult asthmatics cut back on medication because of cost 1 31% of adults adopt one of the following strategies to cope with out-of-pocket (OOP) costs from 2005 survey 2 Ø Cut back on use Ø Borrow money (more debt) Ø Forgo basic needs such as food or heat 1. 2. Piette JD et al. Am J Pub Health 2004; 94: 1782 -87 Heisler M et al. J Behavior Med 2005; 28: 43 -51

Patient-Physician Drug Cost Discussions l Only 43% of primary physicians discussed cost of medications with more than 50% of senior patients in last 30 days 1 Ø l 40% of physicians did not discuss cost with a patient in last 30 days but wished they had 1 Ø l l 65% of discussions initiated by patient Perceived barriers: lack of time, lack of awareness of problem, “little I can do anyway” Of 660 older adults who underused medication, 66% reported that no one asked them about their ability to pay 2 Risk of under using medications due to cost is directly related to patients’ trust in their physicians which in turn is related to communication style 3 1. 2. 3. Beran MS et al. J Am Geriatr Soc 2007; 55: 102 -7 Piette JD et al. Arch Int Med 2004; 164: 1749 -55 Piette JD et al. Arch Int Med 2005; 165: 1749 -55

Patient Assistant Programs (PAPs) l l l Charitable programs offered by pharmaceutical companies to patients of any age Provide free medications (branded prescriptions) to patients Generally patients must meet the following requirements: U. S. residency Ø No prescription drug coverage Ø Low income Ø – < $20, 800/year (single) and < $28, 000/year (couple) – Little or no savings or liquid assets Ø l l Long term medication needs Program available for almost every medication Exceptions to low income limits Astra Zeneca: < $30, 000/year (single) and < $40, 000/year (couple) Ø GSK: < $26, 000/year (single) and < $35, 000/year (couple) Ø

Pros and Cons of PAPs For the Patient l l Pros Decreased out-ofpocket expenses Access to needed medications Reduced emotional and financial stress Improved health outcomes l l Cons Limited supply of meds (3 months) Complex application and reapplication process Long wait times (2 months) Most meds only delivered to MD’s office

Pros and Cons of PAPs For the Healthcare Provider Pros l l l Increased patient compliance with course of treatment Ability to provide highest quality of care Decreased hospitalizations and nursing home placements Healthier and more satisfied patients Allows sample medications to be used for other purposes l l l Cons Complex application process Time consuming Limited patient eligibility secondary to income Meds only delivered to MD’s office Long wait times

PAP Costs to Physician Office Practices l l l Study published in 2007 of PAP process in free-standing, inner-city Midwestern health clinic * Time and motion study using medical assistant with PAP application experience One representative drug from each of 32 pharmaceutical companies used Costs included personnel time, printing costs, and supply costs Results Average application cost = $25. 18 (SD = $17. 23) Ø Personnel time accounted for 50% of costs Ø Total annual clinic cost ranged from $10. 42 per patient for 1 application per year to $46. 30 per patient for 4 applications per year Ø * J Managed Care Pharmacy 2007; 13: 506 -14

Web Sites to Access PAPs l www. rxassist. org Ø Rx Assist – funded by Robert Wood Johnson Foundation l www. needymeds. com Ø Non-profit founded by family doc and social worker l www. pparx. org Ø Partnership for Prescription Assistance Ø Sponsored by Ph. RMA l www. healthwellfoundation. org Ø Assistance for patients with certain diseases Ø Primarily covers expensive chemotherapeutic and biological agents

PAP Software Programs: PAPRx Tracker l Obtain from Needymeds. com Ø Designed for small to medium practices and organizations Ø Data needs to be entered only once Ø Reminders keep users up-to-date Ø Up to four staff members can use the program Ø Web-based program and password protected Ø Monthly charge for 1 to 150 participants is $2 each. The next 150 applicants are free and for more than 300, the cost is $1 each l l Email: paprxtracker@needymeds. com Phone: 215 -965 -8291

Drug Discount Card Programs l l l l Provided by major pharmaceutical companies Provide discounts on branded products from company – drugs are not free Income restrictions less severe than PAPs Patient cannot have other prescription drug coverage or be eligible for Medicare Part D No enrollment fee After application process, patient receives discount upon presentation of card to pharmacy Unable to determine amount of discount before filing application Can still be significant costs for patient

Together Rx Access l l www. togetherrxaccess. com 22 pharmaceutical companies Ø Ø Ø l l Astra Zeneca Bristol-Myers-Squibb GSK J&J Novartis 25%-45% discount Income limits: <$30, 000 singles Ø <$40, 000 couples Ø

Pfizer Pfriends l l l www. pfizerhelpfulanswers. com Average of 32% off retail price Income limits: <$30, 000 singles Ø <$40, 000 couples Ø

Merck Prescription Discount Program l l l www. merck. com/merckhelps 15%-20% savings off of retail price No income limit

Generic Drug Discount Programs – Local Chain Pharmacies l No limits on income or insurance coverage l Wal-Mart and Target Ø $4 for month’s supply for many generic drugs, old and new l K-Mart Ø More limited formulary than Wal-Mart and Target Ø No monthly supply Ø 3 month supply for $15 l Have patients pay cash and avoid using insurance cards Ø Cost of generics often artificially inflated

Generic Drug Discount Programs – Internet Pharmacies l l l Legitimate mail order pharmacies specializing strictly in generic prescription drugs Carry newly approved generics at lower price than found in chains Rx Outreach (www. rxoutreach. com) Ø Income limits, but proof not necessary – <$31, 200 (single), <$42, 000 (couple) Ø Over 125 different medications Ø 3 month supply for $20 – Tier 1 drugs Ø Also Tier 2 ($30) and Tier 3 ($40) Ø No shipping charge

Generic Drug Discount Programs – Internet Pharmacies l Xubex (www. xubex. com) Ø Income limits with documentation of proof Ø 3 month supply for $20 - Tier 1 Ø Tier 2 for $30 Ø Can also get 180 and 360 day supply Ø Shipping charge of $3. 85 per order

Mail Order Generic Drugs Some Examples for $20 -$30/3 Months l l l l l Albuterol inhaler Amlodipine (new) Benzodiazepines Bupropion Carvedilol (new) Cetirizine (new) Finasteride Fluticasone (new) Mirtazipine l l l l Oral contraceptives Phenytoin Simvastatin Steroid creams Tamoxifen Tramadol Warfarin Zolpidem (new)

Medicare Prescription Drug Plan (Part D) l l l Medicare Modernization Act of 2003 (MMA) Plan took effect January 1, 2006 Medicare eligibility Ø > 65 years old or Ø Disabled > 24 months and drawing SS disability during that time or Ø ESRD or ALS l l Prescription Drug Plans (PDPs) are provided by private companies approved by Medicare Over 50 PDPs for patients to choose from in Virginia Eligible patients must enroll with a PDP between November 15 th and December 31 st each year Enrollment is voluntary

More Medicare Part D Rules l l Penalty fee of 1% of premium will be added to premium for every month an eligible beneficiary delays enrollment (no limit to amount of penalty) Only Medicare beneficiaries not subject to penalty are those notified by mail that their current drug benefits are better than Part D Ø VA, TRICARE, retiree drug benefit from employer, etc l l l PDPs must send Annual Notice of Change by 10/31 to all members PDPs may change formulary and drug prices at anytime after January 1 as long as they give 60 day notice PDP members can only change PDP plans once a year on January 1.

2007 Families USA Report on PDP Drug Costs l l PDPs negotiate directly with drug companies on costs For 1 st quarter of 2006 average drug costs rose 3. 9% (CPI rose 1. 1%) From 4/06 to 4/07 costs of top 15 drugs rose 9. 2% (CPI rose 2. 4%) Cost of top 20 drugs through VA is 58% lower than cost through PDPs

Standard Prescription Drug Coverage for 2008 l l Monthly premium varies from plan to plan $275 deductible starting January 1 From $275 to $2, 510: You pay 25% of drug costs ($558. 75) Between $2, 510 and $5, 726. 25: You pay 100% of drug costs ($3, 216. 25) Ø Coverage Gap or “Doughnut Hole” l After $5, 726. 25 in drug costs and $4, 050 in outof-pocket spending ($275 + $558. 75 + $3, 216. 25): You pay only 5% of drug costs (Catastrophic Coverage)

OOP Costs as Percent of Total Drug Costs for 2008 $2, 510 100% Deductible $275 $5726 100% “Coverage Gap” 25 % 5% BENEFICIARY MEDICARE

Out of Pocket (OOP) Costs in Relation to Total Drug Costs for 2008 l Premium: $40/mo or $480/yr l Deductible: $275/yr l If drug costs up to $2510 over 1 year Ø OOP = $1314 or about l If 52% (best case) drug costs up to $5726 over 1 year Ø OOP = $4530 or about l OOP 79% (worst case) costs are 5% of drug costs above $5726

Medicare Gap Coverage l Most patient assistance programs (PAPs) provided by pharmaceutical companies also offer Medicare Gap coverage l Income limits are the same as regular PAPs l Must still use PAP application process l Exceptions Ø GSK has higher income limits Ø Astra. Zeneca provides meds through local pharmacy at $25/month if income < $30, 000 and at least 3% of income already spent on drugs (AZ&me Program)

Extra Help for Low Income Elderly Group 1 Group 3 Full Medicaid & SSI Premium $30. 10/month Group 2 QMB’s, SLMB’s & QI’s 135 -150% FPL $0 $0 (Standard Plan) Sliding scale based on income (Standard Plan) Deductible $275 yearly $0 $0 $56 Coinsurance up to $4, 050 out of pocket $1/$3. 10 co -pay $0 –NH res. $2. 15/$5. 35 co-pay 15% coinsurance Catastrophic 5% or $2/$5. 35 copay $0 $0 $2. 15/$5. 35 copay

How to Delay Patients from Getting Dunked in the Doughnut Hole l Identify patients with income 135% 150% FPL Ø Must voluntarily apply to SS for extra help l Before starting new drug make sure it is on patients PDP formulary Ø Have patient bring formulary in or access web site Ø Switch to lower tier agent of same class l Switch to generic drugs, if possible Ø Pay for $4/month generics OOP

How to Delay Patients from Getting Dunked in the Doughnut Hole l l l Evaluate if patient qualifies for PAP gap coverage Encourage patient to compare PDPs during new enrollment period each Fall and enroll in least expensive program Do not choose PDP because of name recognition or because spouse is enrolled in plan Ø 40% of enrollees signed with United Healthcare or Humana PDPs in 2007

Steps to Finding the Best Plan @ www. medicare. gov 1. Compare Medicare prescription drug plans → 2. Find and Compare plans → 3. 4. General plan search → Zip code, age range, health status, no current drug plan, no drug coverage, not eligible for extra help → 5. Get drug costs for available plans → 6. Enter each medication → Search for least expensive Medicare prescription drug plan 7.

Find the Best PDP at www. medicare. gov

MMA Approval Process by U. S. Congress – An Inconvenient Truth l l l l Bill written by House Energy and Commerce Committee chaired by Billy Tauzin (R-LA) with significant input from pharmaceutical, insurance , and managed care industries Bill prohibits Medicare and federal government from using its vast purchasing power to negotiate lower drug prices Bill of over 1, 000 pages first seen by House members on morning of 11/21/2003 Vote by House took place at 3 AM the following morning after keeping voting machines open for 3 hours instead of 15 minutes and ordering CSPAN cameras to be turned off During that 3 hour window representatives who were voting “no” were threatened or lied to. “It was the ugliest night I have ever seen in 22 years. ” Dan Burton (R-IN) “I saw a woman, a member of the House, crying when they came around to her, trying to get her to change her vote” Walter Jones (R-NC)

MMA Approval Process by U. S. Congress – An Inconvenient Truth l l l Bill originally estimated to cost $395 billion over 10 years 25% of bill consists of incentives to employers and managed care companies Richard Foster, auditor for HHS estimated bill to be $157 billion higher in June 2003, 5 months before passage Tom Scully, head of Medicare and Foster’s boss, repeatedly threatened to fire Foster if he revealed his figures to Congress before the vote Vote carried after last resistant law makers were assured of lower cost estimate by Scully Total estimated cost over 10 years by White House Budget Office in February 2005: $1. 2 trillion

Where Are They Now? l l l Billy Tauzin – resigned House of Representatives in February, 2004 to become CEO of Ph. RMA, the chief lobbying organization for the pharmaceutical industry, with a salary of $2 million per year Tom Scully – resigned in December, 2003 to join law firm as lobbyist to represent drug companies, a job negotiated while helping to write bill Paul Morrisey, chief of staff of House Energy and Commerce Committee – lobbyist for Novartis and Hoffman -La Roche John Mc. Manus, staff director of Ways and Means subcommittee on Health – head of lobbying firm with clients Ph. RMA, Pfizer, Lilly, and Merck Linda Fishman, House Finance Committee – lobbyist for Amgen Plus 3 other House committee staff members who helped write bill became lobbyists shortly afterwards