The costs of prescription drugs in the U.S. is rapidly rising, with more brand-name drugs increasing their list price in the first half of 2021 than all of 2020.
Below, 10 health system pharmacy executives share what they tell patients who are unable to afford their medication.
Onisis Stefas, PharmaD. Vice President and Chief Pharmacy Officer at Northwell Health (New Hyde Park, N.Y.). We would first evaluate the prescription for clinical appropriateness and determine if there was a less expensive therapeutic equivalent. If the medication is the best option for the patient, our team collaborates with members of the interprofessional care team to resolve outstanding payor-related issues, such as prior authorizations. In addition, patients 65 and older may qualify for additional drug coverage benefits through the NYS EPIC program.
We will explore opportunities related to manufacturer copay cards, free drug programs and foundational assistance that may benefit the patient. Our team works diligently to educate our patients about eligibility and facilitate patient enrollment across all applicable programs to lower out-of-pocket expenses. It is important to reassure our patients that we are committed to minimizing the many barriers to effective care so that they can focus on their health and well-being.
Elie Bahou PharmD. Senior Vice President and Chief Pharmacy Officer at Providence (Renton, Wash.). Providence would route the patient through one of our medication assistance programs (MAPs). If an MAP is available at the patient's hospital or region, the patient may be connected through one of our financial advocates who will help take the patient through the review and approval process. Since there are over 600 different grant, foundation, and manufacturer programs available to patients, it is important that a patient is connected to one of Providence’s MAPs. Directing patients to the best form of assistance requires a considerable amount of planning, training, and experience. Moreover, our MAPs have access to tools that can quickly identify and apply for medication assistance.
Firstly, Providence would conduct a clinical review of the patient’s treatment plan to determine the best course of action and the most appropriate drug to be administered. Next, Providence would examine the patient’s insurance and if the drug’s manufacturer offers copay assistance, such as copay cards. Commercial insurance patients may qualify for copay cards from the drug company dependent on 1) patient income, 2) manufacturer availability, and 3) insurance approval. Medicare patients likely would have to qualify for assistance from foundations, as copay cards normally not an option for government plans. This would vary by diagnosis.
Drugs like Keytruda, Opdivo, Avastin, etc. may often be accessed free of charge through the drug company if denied by insurance.
If none of those options are available to the patient, the patient may receive assistance through the hospital charity care. If charity care is available at the patient’s hospital and if the patient qualifies for the care, a discounted cash payment may be offered.
Sophia Alfonso, PharmD. Pharmacy Manager of Retail Services at Moffitt Cancer Center (Tampa, Fla.). I would say, "Don’t panic! There are many resources that our team of dedicated pharmacy specialists can help you navigate so that you can receive the treatment that is best suited for you. There are charitable grants and manufacturer programs and the pharmacy and financial team will work with the clinical team in an effort to make your treatment affordable."
Gene Rhea, PharmD. Associate Chief Pharmacy Officer of Retail and Specialty Pharmacy Services at Duke University Hospital (Durham, N.C.). At Duke Health, we have many resources at our disposal to assist patients if they have financial barriers to medication access. This includes a dedicated team of pharmacy technicians that work as part of our patient assistance program.
These technicians are highly skilled and trained in the variety of financial assistance programs that are available to patients that are prescribed high cost medications. Providers can refer patients directly to the Patient Assistance Program team. Team members work closely with the patient and their providers to ensure each patient understands their options.
Many times, if the patient does not have government provided insurance (i.e. Medicare) they may qualify for a manufacturer assistance program, and our team walks the patient through the application process. If the patient doesn’t qualify for manufacturer assistance, there are often grants or foundations that can provide out of pocket cost assistance.
Lastly, if the patient is uninsured they may qualify for a patient assistance program where the manufacturer ships the medication to them free of charge. In each scenario, our team performs a benefits investigation and works with the patient during the entire application process, and follows up with them if those programs need a renewal in the future.
Krist Azizian, PharmD. Chief Pharmacy Officer at Keck Medicine of USC (Los Angeles). At Keck Medicine of USC, we understand that the financial burden for high-cost medications creates additional strain on patients at a time when they are most vulnerable and in need of care. To that end, we have created a patient assistance program with dedicated resources to help eligible patients in need of financial help navigate the various available payment options.
These range from copay assistance to up-to-full coverage of a medication through pharmaceutical manufacturers’ patient assistance programs. Our goal is to create patient
awareness of the various options while ensuring a seamless process so patients can receive exceptional care without an overwhelming financial burden.
Carla Suslov. Pharmacy Business Manager at St. Luke’s Health System (Boise, Idaho). At St. Luke’s Health System, we found that we were routinely encountering patients that were going to heroic efforts to obtain their medications, patients who are receiving loans or assistance from family, refinancing their home, accruing large credit card debt, working second jobs and some even coming out of retirement to ensure they could pay for their high cost medications. Alternatively, and even more concerning, was the reality that some patients may not even start their therapy due to financial barriers, a scenario that created higher risk for emergency department visits, hospital admissions and avoidable life threatening situations.
In response, St. Luke’s created a Medication Access Team (MAT), a team of highly skilled pharmacy technicians that directly respond to referrals from clinics and providers for patients that have identified financial barriers. This team reaches out to the patient on the same day the referral is received, conducts a thorough assessment of the patient’s medication needs and financial situation, helps them navigate available programs, and connects them to available drug assistance resources. MAT also works with the St. Luke’s outpatient pharmacies to provide same-day emergent fills for patients through an internal assistance fund, and continues to follow them to ensure they do not have any gaps in coverage.
MAT secures an average of $5 million each month in awarded medication assistance from internal and external sources. There has been an overwhelming and humbling response from patients, who have called us, sometimes in tears, to express gratitude for this service. Patients now receive assistance with their high cost medications and have someone to contact when they are faced with additional medication access challenges.
While there have been some challenges such as navigating complex issues with prior authorizations, failed copay card payments, gaps in coverage, and medication access issues for our rural patients, the team continues to find creative ways to overcome these issues. Our goal continues to be to provide systemwide, comprehensive medication access support for our patients while relieving the burden for our providers and clinical staff as part of being this community’s trusted healthcare partner.
Rebecca Bean, PharmD. Senior Vice President and Chief Pharmacy Officer at Novant Health (Charlotte, N.C.). We start by getting the patient cost share as low as possible through copay cards, coupons, or any other funding source to offset medication expense. We look under every stone to see where we can find medication assistance resources. If the medication is still cost prohibitive we will work with the prescriber and patient to come up with a safe, effective and affordable treatment option.
Joe Voelkel. Assistant Vice President of Retail Pharmacy Network at RWJBarnabas Health (West Orange, N.J.). Affordability of medications can be challenging when discharging a patient from a medical center. Outpatient pharmacies must provide discharge medications based on the patient’s prescription coverage or in some instances no prescription coverage at all. That being said, the patient needs to be discharged on medications that aim to prevent readmission.
These potential questions may arise. Can the patient afford their copay of the discharge medications? Are the medications covered by their insurance? Can we introduce a patient assistance program where applicable? Is there a manufacturer coupon available to lower the copay? Is there an option to change the medication to a less expensive alternative?
An example that comes to mind is one where an uninsured patient needed to be discharged on a medication that was over $20,000. We were able to use the 340B program to lower the out of pocket copay to an affordable price the patient was capable of paying.
Programs available to outpatient pharmacies that help lower patient medication costs are manufacturer coupons, the 340B program, programs that provide donated medication and generic drug clubs which provide a formulary of low cost medications. Pharmacists may contact the prescriber to change medications to an equally effective, lower price alternative.
Amir Emamifar, PharmD. Vice President and Chief Pharmacy Officer at Temple University Health System (Philadelphia). We look for a patient assistance program from the manufacturer or any other site that may have access to medication. If unsuccessful, we try for any grant or funds that may be available. We will provide the medication if it is life saving or there are no other alternatives for the patient.
Gary Kerr, PharmD. Chief Pharmacy Officer at Baystate Health (Springfield, Mass.). Most notably, our embedded specialty pharmacy liaison model features formally trained expertise in financial assistance and prior authorization across all covered offices/areas. We also are capable of handling financial assistance through our retail pharmacy in specific situations.
These services complement our enhanced integrated and defragmented care model quite nicely. Many new metrics are tracked and reported regularly to confirm our results.
Depending on the drug and source of the order, we direct inquiries to the appropriate pharmacy resources.