Specialty Pharmacy + Medication
Assistance Programs
Presenters:
Scott Sterrett, PharmD
Manager, Specialty Pharmacy
Beaumont Health
FACULTY DISCLOSURE
The faculty reported the following financial relationships or
relationships to products or devices they or their
spouse/life partner have with commercial interests related
to the content of this CE activity:
- Scott Sterrett - Nothing to disclose
Who’s in the Audience?
IDN Pharmacy ExecutiveA.
Other IDN ExecutiveB.
Pharmaceutical IndustryC.
OtherD.
Tell Me About Your Site…
A. No specialty pharmacy (SP)
B. In process of developing/implementing SP
C. Well-established SP
D. Don’t know/not sure
Session Objectives
1. Detail the factors causing uncertainty and financial
hardship for pharmacy patients.
2. Identify three assistance programs that can help mitigate
these burdens.
3. Discuss the impact these programs have on patients and
providers.
What Are Specialty Drugs?
• High cost
• Treatment requires special monitoring
• Treats orphan, uncommon, or rare disease
• Special handling, storage, or distribution
• Limited distribution from manufacturer
• Treats disease already classified as specialty
• Requires patient administration training
EMD Serono Specialty Digest: 10th Edition (2014)
Specialty Spans Multiple Care Settings
• Route of Administration
–Oral and self-injectable
–Infusion centers
–Home infusion
• Insurance Coverage
–Prescription benefit
–Medical benefit
The Rising Cost of Specialty Medications
Peterson Kaiser Health System Tracker. Recent and
forecasted trends in prescription drug spending (2017)
Increased Cost-Sharing
• Specialty drug tiering
• High-deductible health plans
• Copay accumulators
Specialty Drug Tiering
76• % have specialty drugs in separate cost-sharing tiers
59• % have two or more specialty tiers
Median specialty copayment is $• 100
Average specialty copayment is $• 107
EMD Serono Specialty Digest: 10th Edition (2017)
The Rise of High-Deductible Health Plans
National Center For Health Statistics. National Health Interview Survey (2018)
HDHP Cost Sharing
EMD Serono Specialty Digest: 10th Edition (2017)
Copay Accumulators
• Manufacturer copay cards do not count toward
prescription deductible or out-of-pocket costs
• Many plans began adopting in 2018
• “Out of Pocket Protection Program”
• “Coupon Adjustment: Benefit Plan Protection Program”
Fein AJ. Drug Channels. http://www.drugchannels.net/2018/
01/copay-accumulators-costly-consequences.html
The Result…
Ease of Affording Prescription Medications
45%
28%
17%
9%
1%
Very Easy
Somewhat Easy
Somewhat Difficult
Very Difficult
Don't Have to Pay
Peterson Kaiser Health System Tracker. Recent and
forecasted trends in prescription drug spending (2017)
Financial Barriers Lower Adherence
• Globally1
–20-30% of prescription medications never filled
–50% of medications for chronic conditions taken incorrectly
• Medicare patients prescribed imatinib2
–32% failed to fill within 6 months
–Lack of low-income subsidy correlated with failure to start therapy
1Ann Intern Med 2012;157(11):785-95.2J Clin Oncol 2016;34(36):4323-28.
Financial Barriers Lower Adherence
• All insured patients who applied for copay asssistance3
–42% reported significant or catastrophic financial burden
–46% reduced spending on food and clothing
–46% used savings to defray out-of-pocket expenses
–20% took less than prescribed amount
–19% partially filled prescriptions
–24% avoided filling prescriptions entirely
3Oncologist 2013;18(4):381-90.
Types of Financial Assistance
Manufacturer1. -sponsored copay cards
Charitable foundations2.
Manufacturer3. -sponsored free drug programs
Drug replacement programs4.
Health system financial assistance5.
1. Copay Cards
• Manufacturer-sponsored
• Available for most medications
• Copay amount and maximum
benefit vary
• Generally no financial
requirements
• Cannot be used for federally-
insured patients
2. Charitable Foundations
• Available for many specialty disease states
• Eligibility and funding vary by program
• Patients with federally-funded insurance are eligible
• Examples
–CancerCare Co-Payment Assistance Foundation
–Chronic Disease Fund
–HealthWell Foundation
–Patient Access Network Foundation
3. Free Drug Programs
• Manufacturer-sponsored
• Need-based, generally
percent of FPL
• Require insurance denial or
proof of uninsured status
• Can be used for all patients
4. Drug Replacement
Manufacturer• -sponsored
Drug• -specific program
Pre• -administration vs. post-administration
May use for off• -label indications
Require insurance denial or proof of uninsured status•
Can be used for all patients•
5. Health System Financial Assistance
• Use as last resort
• Charity care/340B benefit
• Eligibility varies by system
Patient Benefits
• Increase access to medications
• Supports adherence
• Improved outcomes/disease management
• Reduced financial burden
Provider Benefits
• Better manage population health
• Decrease emergency visits/readmissions
• Decrease bad debt/charity care (maybe)
• Increase specialty pharmacy revenue
Medication Assistance Survey
Informal survey of Vizient Specialty Pharmacy listserv•
Assess types of assistance provided to patients receiving •
specialty medications
Seven responses from Academic Centers•
Vizient AMC Network Survey (2018)
7 7 7
6
MFG COPAY MFG FREE DRUG THIRD PARTY SYSTEM FUNDS
Vizient AMC Network Survey (2018)
What types of financial assistance
do you provide for specialty patients? (n=7)
What is the approximate percentage of
funds provided by each source (n=6)
58
28
15
MANUFACTURER CHARITY HEALTH SYSTEM
Vizient AMC Network Survey (2018)
For what medications do you provide
health system-sponsored funds? (n=6)
5 5
4
ORAL SELF-INJECTABLE INFUSED
Vizient AMC Network Survey (2018)
Have you seen a decrease in the amount of system-sponsored
funds since implementing your specialty pharmacy? (n=6)
3
2
1
YES NO UNSURE
Vizient AMC Network Survey (2018)
BEAUMONT HEALTH SPECIALTY
FINANCIAL ASSISTANCE
Case Study
Beaumont Health Overview
• 8 hospitals; 3,429 beds
• 5,000 physicians
• 187 outpatient sites
• 175,688 discharges (2017)
• $4.4 billion net revenue (2017)
• 5 infusion centers
• Specialty pharmacy
implemented 2014
Locations of Care
• Specialty Pharmacy
–Oral and self-injectable
–Serve employees, clinics,
and BH providers
–Pharmacy benefit claims
• Infusion Centers
–Infused therapies
–Variation in funding
assistance across sites
–No integration with SP
Specialty Pharmacy Assistance
• Staff
–2 dedicated Prior Authorization Technicians
–Comprehensive approach to medication access
• Types of Assistance Offered
–Manufacturer-sponsored copay cards and free drug
–Charitable organizations
Specialty Pharmacy Financial Assistance Secured
$1,142,780
$4,220,340
$2,654,288 $3,798,547
110
243
395
615
0
100
200
300
400
500
600
700
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
2014 2015 2016 2017
Pat
ien
ts S
erv
ed
Ass
ista
nce
Se
cure
d
Over $11.8 million secured to-date
Infusion Center Assistance
• Relatively new process for infusion centers
• Primarily drug replacement and copay cards
• Troy Ambulatory Infusion Center (2017)
–$1.26 million worth of drug replacement
–$456,000 decrease in bad debt due to copay programs
Financial assistance touches the
lives of both patients and providers
Contact Information
Scott Sterrett, PharmD
Manager, Specialty Pharmacy
Beaumont Health