Patient Advocacy. Access, Affordability,

and understanding treatment costs .

Presented by: Dean Gruber, RPh, Pharmacy Manager at Community, A Walgreens Pharmacy David Straseski MSSW, LCSW, OSW-C, Lead Oncology Social Worker at Aurora Cancer CareLauren Marquardt, UW Pharmacy Student-Class of 2015

2

3

Insurance Types • State Funded Insurance

– Wisconsin ForwardHealth• BadgerCare Plus

– Health care for children, pregnant women, and adults» Adult with income at or less than 100% FPL» Eligible patients above 100% FPL are asked to use the

healthcare exchange, Medicare D, Senior Care or other programs

» Eligibility exceptions can occur

Insurance Types

• State Funded Insurance– Wisconsin ForwardHealth

• Medicaid for Elderly, Blind or Disabled – Eligibility:

» Age 65 or older, blind, disability» Family income and assets are at or below monthly

program limit » United States citizen or qualifying immigrant

5

Insurance Types

• State Funded Insurance – Wisconsin ForwardHealth

• SeniorCare Prescription Drug Assistance – Wisconsin residents who are 65 or older

» Must pay $30 annual enrollment fee per person » Only income is counted. Assets such as bank accounts,

insurance policies, home property are not counted» Four levels of enrollment based on income » Subject to certain annual out-of-pocket expense

requirements depending on annual income. » Drug coverage varies by level of enrollment

6

Insurance Types • State Funded Insurance

– Wisconsin ForwardHealth• SeniorCare Prescription Drug Assistance

– Wisconsin residents who are 65 or older » Can be stand-alone credible coverage for patients who

would be required to pay a fee for late enrollment into Medicare Part D.

» Can also be a supplement to Medicare Part D coverage.

7

Insurance Types • Affordable Care Act (Non-Medicare)

– Pick the insurance that fits your needs from the Marketplace

– Metal Tiers • Tiers are assigned an “actuarial value”

– Refers to the healthcare expensed the plan will cover – The higher the actuarial value, the lower the out-of-pocket

cost

9

Insurance Types

• Bronze plans will have lower premiums, but higher out-of-pocket costs (60% coverage)

• Platinum plans will have higher premiums, but lower out-of pocket costs (90% coverage) – Bronze Plan– Silver Plan– Gold Plan – Platinum Plan

10

Premium Subsidies Available • Premium cost subsidies will be available to people with

incomes from 100% of the Federal Poverty Level to 400% of the Federal Poverty Level (FPL).

• Applies to silver plans only. • Examples of 400% of FPL in Wisconsin:• 1 member in family $ 45,960• 2 members $ 62,040• 3 members $ 78,120• 4 members $ 94,200• 5 members $110,280• 6 members $126, 360• 7 members $142,440• 8 members $158,520

11

Insurance Types • Commercial Insurance

– Plan coverage varies widely in benefit design based on the type of plan

12

Insurance Types

• Federally Funded Insurance – Medicare

• Federal healthcare coverage for people 65 or older, or those under 65 found disabled by Social Security Administration.

13

Insurance Types

• Federally Funded Insurance – Medicare A

• Covers:– Inpatient hospitalizations– Skilled Nursing Facility– Inpatient psychiatric care– Hospice

• Premium free if have enough Social Security work quarters

14

Insurance Types • Federally Funded Insurance

– Medicare B• Covers:

– Doctor visits – Outpatient services

» Infusion administration» Medication coverage for VELCADE®

– Certain oral oncology medication» oral Cytoxan® (cyclophosphamide)

– Services Part A does not cover

• Late enrollment penalty if you do not sign up when first eligible.• Monthly premium: $104.90

15

Insurance Types • Privately run under Federal guidelines

– Medicare supplement insurance (Medigap)• Sold by private insurance • Help pay health care costs that are not covered by

original Medicare – Deductibles, co-insurance, and co-payments

• Medigap does not work with Medicare Advantage Plan

16

Insurance Types • Federally Funded Insurance

– Medicare C (Medicare Advantage Plan) • Covers:

– Offered by private companies approved by Medicare – Get Medicare A and B coverage from your Medicare

Advantage Plan – Most Medicare Advantage Plans offer Part D prescription

coverage » Can vary depending on the type of plan

– Coverage is variable and dependent on the plan

17

Insurance Types • Privately run under Federal guidelines

– Medicare D• Covers:

– Prescription Drug Coverage

• Premium varies depending on plan• Co-pays vary per drug, plan, and pharmacy

18

Insurance Types • Federally Funded Insurance

• How does Medicare Part D work?– Broken down into four parts 1. Part 1: Initial $310 deductible2. Part 2: Coverage

- 75% covered by Medicare, up to 25% covered by individual- Enter Doughnut Hole at drug costs of $2850

3. Part 3: The Coverage Gap “The Doughnut Hole”-Medicare Part D plan will pay 28% of your generic medication

costs and the Brand-name drug manufacturer will pay 52.5% of your brand-name drug expenses

4. Part 4: Catastrophic Coverage - Co-payment of 5%

19

Co-Pay Cards • Co-pay cards are available for many branded

products for treatment and side effects – Cannot be used for patients with Medicaid or

Medicare– Can be used in addition to commercial and most

ACA plans

20

Co-Pay Assistance Foundations • All insurances eligible, including Medicare Part

D and SeniorCare• Dependent upon income level, household size,

diagnosis and medication• Funding based upon a grant through an

organizations, exact details are based upon each individual organization and patient specific factors

21

Manufacturer Coverage • Some individuals may be eligible for direct

coverage through the manufacturer based on financial needs

22

Co-Pay Assistance Foundations • Four of the main organizations that have

funding for multiple myeloma1. Leukemia and Lymphoma Society

– http://www.lls.org

2. Patient Access Network Foundation – www.patientaccessnetwork.org

3. Chronic Disease Fund – www.cdfund.org

4. Patient Advocate Foundation – www.copays.org

23

Typical Case: Myeloma patient on an oral therapy • Average age of onset is 70 years of age

– Most patients will have Medicare Part D coverage

• Medicare Part D– Deductible: $310– Coverage: 75% covered by Medicare up to $2850– Donut Hole: Medicare covers 28% for generic and

manufacturer covers 52.5% for brand, rest is paid by patient

– Catastrophic: 95% coverage 24

Typical Case Scenario

– Revlimid® Cost: $9,000 - $12,000 per cycle

25

Deductible $262

Coverage $635

Coverage $635

Donut Hole $1759

Donut Hole $1759

Catastrophic$ 143

Catastrophic$ 143

Patient has not met $310 deductible

$2850-$310 = $2540

$2540 (25%)= $635

$3704(47.5%) = $1759 $2877 (5%) = $143

Total patient cost without copay assistance = $2,799

Copay assistance grant will cover total cost of $2,799

Typical Case Scenario • Patient has made it to catastrophic coverage with

one Revlimid® fill • For additional refills the patient will pay 5% of

prescription costs in catastrophic (approximately $450-600 per refill)

• Coverage for first fill and refills are typically not exceeded by the yearly grant amount

– Leukemia and Lymphoma Society Grant • $10,000 grant

– Patient Access Network Foundation • $10,000 grant

26

References Forward Health- The Connection to Health Care Coverage and Nutrition

Benefits. (July 2014). Retrieved August 15, 2014 from http://www.dhs.wisconsin.gov/forwardhealth/

2014 Poverty Guidelines. (2014). Retrieved August 15, 2014 from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Downloads/2014-Federal-Poverty-level-charts.pdf

How Part D Works? (July 2014). Retrieved August 16, 2014 from http://q1medicare.com/

The Official U.S. Government Site for Medicare. (2014). Retrieved August 16, 2014 from http://www.medicare.gov/

Affordable Care Act. (2014). Retrieved August 16, 2014 from http://www.medicaid.gov/AffordableCareAct/Affordable-Care-Act.html

27

Questions?

28

00/00/2013

thank you