Our Patients Can’t Afford Their Medications – What Happens Now?

1. Our Patients Can’t Afford Their Medications – What Happens Now? Kristin Fox-Smith, BS, MPA University of Utah Pharmacy Administration

2. Topics For Discussion • Medicare Part D Donut Hole • Making the Most of Your Medicare Coverage • Options During the Coverage Gap • SPAP’s • Discount Programs • Vouchers • Patient Assistance Programs

3. Uninsured In America • 6 out of 10 people have delayed seeking healthcare due to cost • 3 in 10 did not fill a prescription due to cost • 2 in 10 cut pills in half or skip doses due to cost

4. Options During the Coverage Gap • $4 generic prescription initiative – started with WalMart in 2006, 331 generics included, this model now adopted at hundreds of retail pharmacies (Target, Kmart) • Of the 10 most prescribed drugs in the United States, only Amoxicillin is available on the $4 plan • 4 of the top 20 prescribed medications are included in this $4 plan • Multiple strengths of drugs on plan are also $4

5. Coverage Gap Options • Most manufacturers do NOT disclose income guidelines for patient assistance, but average income for household of 1 is $32,000 and household of 2 is $45,000 • Must prove patient’s inability to pay out-of-pocket expenses • Coverage IS available for patients with commercial or Medicare Part D coverage!

6. Options During the Coverage Gap • Important that patient continue to use Medicare Part D card! • Plan’s negotiated prices are generally lower than retail, result in patient savings • Money spent on covered drugs counts towards True Out-Of-Pocket (TrOOP) • Part D plan will track spending, and monitor when coverage gap ends, reinstating pharmacy benefits

7. Gap Coverage 2010 • In 2010 1272 plans will provide NO gap coverage • Only 76 plans will offer “some” generic coverage • 229 plans will cover “many” generics • 108 plans will cover all generics • 1 plan will cover all generics and a few brands • 2 plans will cover many generics and a few brands

8. SPAP’s • Prior to the implementation of the Medicare prescription drug benefit in 2006, state pharmaceutical assistance programs (SPAP) helped to fill a critical gap in coverage for Medicare beneficiaries without prescription drug coverage, targeting resources to beneficiaries with relatively low incomes • When the prescription drug benefit went into effect in 2006, many states modified their programs to coordinate benefits with the changes in Medicare, and some states terminated their SPAP’s completely • Some states continued to offer prescription drug subsidies to low-income elderly or disabled individuals as supplemental or “wrap around” benefits to Part D

9. SPAP’s • As of December 31, 2006, CMS recognized 25 states operating 40 distinct “qualified” SPAP’s • Most states that offered pharmaceutical assistance programs in 2003 continue to offer programs in 2007 • Currently nine states operate more than one SPAP and six of these states (California, Delaware, Maryland, Pennsylvania, Texas, and Wisconsin) offer at least one program with limited eligibility, targeting specific disease populations including chronic renal disease • Four states offer two programs that are available to the broader Medicare population

10. SPAP’s • In 2006, the Medicare Modernization Act officially recognized SPAP’s in federal law and provided $62.5 million in funding grants for SPAP’s to educate participants about Medicare Part D plan options and benefits • SPAP’s may not discriminate among the available Part D plans and must offer equal assistance to enrollees in all Part D plans • Payments made by the SPAP must count toward a beneficiary’s true out-of-pocket costs • Costs associated with a beneficiary’s deductibles, copayments, and formulary medications that are paid for by SPAP also count toward TrOOP

11. SPAP’s • As payments from SPAP’s count toward a beneficiary’s TrOOP, enrollees in SPAP’s may reach the catastrophic coverage limit sooner, at which point the enrollee is responsible for only 5 percent of their prescription drug costs • Eligibility for SPAP’s are determined by the individual states and may require applicants to meet income, asset, age, and Part D eligibility requirements

12. SPAP’s • All 25 qualified SPAP’s require individuals to meet income limits • Only two state programs use 150% of FPL, which is also the income limit for the Part D low-income subsidy • All other programs have higher income limits, which is beneficial for the many Medicare enrollees who have modest incomes but are not eligible for the LIS due to incomes that exceed 150% of FPL

13. SPAP’s • Programs in Maryland, Massachusetts, New Jersey, New York, and Virginia extend eligibility to residents with incomes above 300% of FPL • Only two programs require individuals to meet asset tests in order to be eligible for assistance: Alaska and North Carolina • Most qualified SPAP’s require participants to be enrolled in a Medicare Part D plan, and eleven states will work with CMS to automatically enroll applicants in a Part D plan if they are not alreay enrolled

14. Rx Outreach • How to qualify? • You can use Rx Outreach regardless of age or enrollment in any other discount or patient assistance program • Brand and generic medications available in 90 and 180 days supply (tier 1 and 2 available in 180 day supply, tier 3 for a 90 day supply) – more than 150 medications available • Average cost is $20 for a 180 day supply • Patients eligible up to 300% of FPL

15. Discount Programs – Rx Outreach

16. Rx Outreach • Rx OutreachExpress Scripts Specialty Distribution Services, Inc.PO Box 66536Saint Louis, MO 63166-65361-800-769-3880

17. Patient Assistance Opportunities • Abbott (Gengraf) – allows assistance for any insured or non-insured patient, Medicare Part D covered as well. Income guidelines not disclosed, approximately $45,000 annually • Astellas (Prograf) – allows assistance for any insured or non-insured patient, Medicare Part D covered as well. Income guidelines also approximately $45,000 annually

18. Patient Assistance Opportunities • Novartis (Neoral/Myfortic) – does not allow insured patients, commercial or Medicare. Income guidelines approximately $45,000 annually • Pfizer (Vfend) – allows for Medicare Part D recipients who have reached their doughnut hole to receive free drug, does allow assistance for commercial/private insured. Pfizer does allow “hardship” appeal for insured patients with no ability to pay for drug. Income guideline for household of one is $20,420, household of two is $27,380

19. Patient Assistance Opportunities • Roche (Cellcept) – allows assistance for insured or non-insured patient, Medicare Part D included. Income guidelines approximately $45,000 annually • Wyeth (Rapamune) – does not allow coverage for insured patients with exception of Medicare Part D patients in doughnut hole. Income guidelines approximately $45,000 annually

20. Cellcept Assistance • Cellcept For Living • Copay Assistance Card • Card good for up to $100 toward every CellCept prescription and refill!

21. Myfortic Assistance • Myfortic Free 30 day Trial Offer • Valid for up to a 30-day supply of Myfortic delayed release tablets (using any combination of 180 mg and 360 mg tablets; can not exceed a total of 2160 mg/day of Myfortic) • Simple to use program - just download the voucher, take it to the pharmacy with a valid signed prescription for 30 days therapy; the pharmacist will dispense it to you for free.

22. Prograf Assistance • Prograf Value Card Program • Enrollment process consists of 3 easy steps. Once activated, this card may be used to instantly save up to $100 on each of your next 12 prescriptions for a total savings of up to $1,200. If your doctor gave you a Prograf: Value Card, you need to enter the 9 digit number printed on the face of your Prograf: Value card. This card can also be activated online, and you can enroll without an identification number

23. HealthWell Foundation • The HealthWell Foundation® takes into account an individual's financial, medical, and insurance situation when determining who is eligible for assistance • Financial criteria are based on multiples of the federal poverty level, which takes into account a family’s size. Families with incomes up to four times the federal poverty level may qualify. The Foundation also considers the cost of living in a particular city or state • The Foundation asks for the patient's diagnosis, which must be verified by a physician signature, and the patient must receive treatment dispensed in the United States • Individuals covered by private insurance, employer-sponsored plans, Medicare or Medicaid may be eligible

24. HealthWell Foundation • When enrolled, the Foundation allocates each patient a grant for full or partial assistance for up to 12 months. Patients then submit invoices or receipts to receive monetary awards. The foundation typically sends awards directly to the insurer, pharmacy, physician, or other provider. However, in some cases it may send awards directly to patients to reimburse them for expenses they must pay themselves • The HealthWell Foundation does not restrict the medications that patients use as long as the medication is approved by the Food and Drug Administration and falls within a funded area. The Foundation also does not restrict the provider or pharmacy that the patient selects

25. HealthWell Foundation • The Foundation is able to help patients receiving treatments for selected diseases • Immunosuppressive treatment for solid organ transplant recipients is covered disease • Cellcept, Gengraf, Myfortic, Neoral, and Prograf are all covered by the Foundation • University has been able to receive assistance for 18 patients, average benefit per year $16,000

26. HealthWell Foundation • Due to overwhelming need this year, the HealthWell Foundation had to close several funds: head and neck cancer, Hodgkin’s disease, multiple myeloma, myelodysplastic syndromes, and non-small cell lung cancer

27. HealthWell Foundation • 37,300 patients assisted in 2008 • $105 + million awarded in 2008 • 14,500 callers assisted monthly • 69,000 patients helped to-date • Recognized by Forbes as one of America’s most efficient charities

28. Patient Services Incorporated • Patient Services Incorporated (PSI) is a non-profit organization primarily dedicated to providing health insurance premium assistance, pharmacy co-payment assistance and co-payment waiver assistance for persons with specific expensive chronic illnesses. • Established in February 1989, PSI has developed into a national organization serving 50 states. Its services are made possible through private/corporate donations and grants. Families requiring assistance in the purchasing/maintaining of COBRAs, high risk insurance pools, conversion policies and open enrollment health insurance plans are given

29. Patient Services Incorporated • Ask anyone to name their most valuable possessions and surely "health" will be rated among the top answers. But for persons affected by expensive chronic medical disorders, "health" becomes an unaffordable luxury instead of a dire necessity. Disorders affecting the blood, lungs, kidneys, nervous or digestive systems are oftentimes treatable, but the annual expense of routine treatment can range from $30,000--$150,000. This translates into annual out-of-pocket co-pay expenses ranging from $6,000 to $10,000--an amount equivalent to a year's rent or mortgage payments. High risk insurance premiums ranging from $3,600 to $17,000 per year can compound that figure and realistically a family's annual out-of-pocket healthcare costs may range from $9,600 to $27,000 per year.

30. Patient Services Incorporated • PSI provides the following programs which will complement any established and existing "patient assistance program". According to the particular chronic illness or medical disorder, PSI can provide one of the following services:Premium Assistance Program • Cobra Payments • High-risk Payments • Open-enrollment Payments • Guaranteed Issue Payments • Full Assistance or Share-of-Cost   • Copayment Assistance Program

31. Patient Services Incorporated • PSI offers bilingual services • 70% of the patients PSI assists transition to a better quality of life within 24 months • PSI assists with over a dozen chronic conditions • PSI has been the trailblazer for patient assistance for 20 years

32. Patient Services Incorporated • Telephone: 800-366-7741 Fax: 804-744-5407 Email: uneedpsi@uneedpsi.org Patient Services Inc.P.O. Box 1602Midlothian, VA 23113

33. Contact Information • Kristin Fox-Smith – Pharmacy Billing Manager, University of Utah • Kristin.fox@hsc.utah.edu