Medication Access to Low Income Clients

1. Medication Access to Low Income Clients Howard Peckman, PharmD, MS Pharmacy Manager NC DMH/DD/SAS Raleigh, NC

2. Objectives • Discuss community resources for patients who do not have health insurance or qualify for Medicaid

3. Epidemiology • There are more than 1.1 million low-income, uninsured people in North Carolina • National numbers show that almost half of the uninsured have at least one chronic illness • The Urban Institute projects that 734,000 North Carolinians will remain uninsured after health reform is implemented

4. Medication for Non-Insured • Medication Access and Review Program (MARP) • North Carolina MedAssist • Free Clinics of North Carolina • Discount Pharmacy Prescriptions (i.e. the $4 prescriptions) • Donated Medications • Sample Medications

5. Medication for Non-Insured Medication Access and Review Program (MARP) • MARP Provides access to Pharmaceutical Patient Assistance Programs in one location. • Each Pharmaceutical Manufacturer sets different qualification rules for patients. • Each Pharmaceutical Manufacturer has different forms to be completed.

6. Medication for Non-Insured Medication Access and Review Program (MARP) • 3800+ medication forms available on one website • Immediate qualification information based on financial info from client • Information entered into MARP, then various forms automatically are populated • Database assists in tracking when re-ordering needs to occur

7. Medication for Non-Insured • MARP locations currently available are at: http://www.ncdhhs.gov/orhcc/services/marp.htm • Web-based MARP started in September 2011

8. Medication for Non-Insured North Carolina MedAssist • http://www.medassist.org/ • Available to all NC residents who are 200% of FPL or less, and who are not active in Medicaid. • $21,780 a year for an individual • $44,700 a year for a family of four

9. Medication for Non-Insured North Carolina MedAssist • In Mecklenburg County, NC MedAssist serves as a Community Pharmacy dispensing free prescription medication • All counties have access to mail order delivery from the Mecklenburg County site (prescriptions must be mailed to client or authorized pharmacy) • 20+ Sites around the State are “Points of Entry”, and qualifying clients can directly receive selected prescription medications free of charge

10. Medication for Non-Insured North Carolina MedAssist • Expanded Statewide in 2009 • Since 2009, dispensed >$10 Million worth of prescription drugs • Have served >32,000 North Carolinians • Medication focus is chronic care, but some acute care medications

11. Medication for Non-Insured (NC MedAssist Selected Formulary) Antidepressants • Amitriptyline (from generic list) • Doxepin (from generic list) • Duloxetine (Cymbalta) • Fluoxetine (Prozac) • Mirtazapine (from generic list) • Nortriptyline (from generic list) • Paroxetine (from generic list) • Trazadone (from generic list)

12. Medication for Non-Insured (NC MedAssist Selected Formulary) Antipsychotics • Asenapine (Saphris) • Haloperidol • Iloperidone (Fanapt) • Olanzapine (Zyprexa, Zyprexa Zydis, Symbyax) • Quetiapine (Seroquel and Seroquel XR) • Ziprasidone (Geodon)

13. Medication for Non-Insured (NC MedAssist Selected Formulary) Miscellaneous Psychiatric Medications • Atomoxetine (Strattera) • Busprione • Carbamazepine, Carbamazepine XR (Tegretol XR) • Oxcarbazepine (Trileptal) • Divalproex sodium (Depakote and Depakote ER) • Lithium carbonate • Donepezil (Aricept) • Rivastigmine (Exelon) • Carbidopa/Levodopa/Entacapone (Stalevo)

14. Medication for Non-Insured (NC MedAssist Selected Formulary) Selected Medications • Atenolol, Clonidine, Propranolol, Simvastatin and many other cardiovascular medications • Metformin, Insulin (various Humulin), Januvia • Levothyroxine (Synthroid) • Omeprazole, Nexium • Asmanex, Proventil HFA, Singulair • Tizanadine • Folic Acid

15. Medication for Non-Insured North Carolina Association of Free Clinics • Approximately 65+ Free Clinics within NC • Approximately 50+ Counties with at least one Free Clinic • http://www.ncfreeclinics.org/

16. Medication for Non-Insured $4 Prescription Details • Target, Walmart/Sam’s, Kroger, Food Lion-$4 (30 day)/$10 (90 day) • Rite-Aid-$9 (30 day)/$16 (90 day) • Harris Teeter/CVS-$10 (90 day), requires a membership fee • Kerr/Walgreens-$12-$13 (90 days), requires a membership fee

17. Medication for Non-Insured $4 Prescription Details • Discounted prescription is linked to a SPECIFIC DOSAGE FORM and QUANTITY • Examples: • Citalopram 20 mg (#30) = $4, but Citalopram 10 mg (#30) = ~$10 • Carbamazepine 200 mg (#60) = $4, but Carbamazepine 200 mg (#90) = ~$12

18. Medication for Non-Insured $4 Prescription Details • http://www.ncdhhs.gov/mhddsas/services/pharmacy/index.htm • Prescription Discount List (1/10)           • Psychotropic Discount List  (7/09)   

19. Medication for Non-Insured $4 Prescription Details Antipsychotics • Fluphenazine (1 mg tab, mostly) • Haloperidol (0.5 mg to 5 mg tab) • Thioridazine (25 mg to 50 mg tab) • Thiothixene (2 mg tab, mostly) • Trifluperazine (1 to 10 mg (Walgreens))

20. Medication for Non-Insured Cost of Generic Antipsychotics (“non-discount” prescriptions) • Risperidone 3 mg daily (range $20-$120/month) • Perphenazine 4 mg BID (approx $60/month) • Olanzapine generic released Oct 2011* • Quetiapine generic release Spring 2012* • Ziprasidone generic release Spring 2012* • *Prices do not decrease until 6-12 months later

21. Medication for Non-Insured Donation of medications • 2009 NC Legislation passed, and written in NC Board of Pharmacy law in 2010 • Any pharmacy, free clinic or dispensing physician registered w/ NC Board of Pharmacy may accept donated medications from other pharmacies

22. Medication for Non-Insured • Long-term Care Pharmacies dispense medications (usually unit dosed in strips or “bingo cards”) • Unused medications due to change in medication/dose or patient expires are sent back to pharmacy • In some situations, pharmacy cannot recycle back into inventory • These medications are segregated, and destroyed (pharmacy pays for destruction fee per pound)

23. Medication for Non-Insured Donation of medications • Cannot accept controlled substances, refrigerated items, or compounded admixtures • Medication must be “in date” for at least 6 more months from time of donation • Final dispensing to patient must be made by a pharmacy, but “intermediates” can collect donations • Pharmacies must maintain separate inventory and document when donated med was dispensed • Receiving pharmacy accepts liability of the medication

24. Medication for Non-Insured Sample Medications • Pros-Immediate access to medication; No cost to patient • Cons-Federal requirements for storage and record keeping; Encourages brand name medications

25. Medication for Non-Insured Sample Medications • Drug Representative Responsibility • Drug Sample Request Form • Recording of Lot numbers distributed • Physical inventory • Expired drug return

26. Medication for Non-Insured Sample Medication Donation?? • A drug sample can be donated by a licensed practitioner or donating charitable institution to a charitable institution in its original, unopened packaging with its labeling intact. • However, the drug sample cannot be donated if: • The drug sample is out of date • The labeling has become mutilated, obscured or detached from the drug package • The drug sample shows evidence of adverse storage affecting stability, integrity, or effectiveness • Recalled or drug withdrawn from market • The drug sample is possibly contaminated, deteriorated, or adulterated.

27. Medication for Non-Insured • Local resources: some counties have county subsidized pharmacies, or charitable services that may be able to help with medications.

28. Questions/Suggestions

29. References • NC Pharmacy Law http://www.ncbop.org/LawsRules/Statutes.pdf • Prescription Drug Marketing Act of 1987 http://www.access.gpo.gov/nara/cfr/waisidx_02/21cfr203_02.html • NC Jails and Inmates with MI and DD 2006 Report http://www.icdri.org/legal/report%20word%20setup.pdf • NC House Bill 1473 http://www.ncga.state.nc.us/Sessions/2007/Bills/House/PDF/H1473v10.pdf

30. Websites MARP • http://www.ncdhhs.gov/orhcc/services/marp.htm NC MedAssist • http://www.medassist.org/ NC Free Clinics • http://www.ncfreeclinics.org/ Discount Prescriptions • http://www.ncdhhs.gov/mhddsas/services/pharmacy/index.htm