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Patient Advocacy. Access, Affordability, and understanding treatment costs.
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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 Care Lauren Marquardt, UW Pharmacy Student-Class of 2015 2
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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
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2014 Poverty Guidelines 4 http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Eligibility/Downloads/2014-Federal-Poverty-level-charts.pdf Family Size100 % FPL 111,670.00 215,730.00 319,790.00 423,850.00 527,910.00 631,970.00 736,030.00 840,090.00
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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
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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
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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
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Insurance Types – Wisconsin ForwardHealth SeniorCare Prescription Drug Assistance – Four levels based on income limits: – NOTE there is no asset limit 1. At or below $18,672 per individual or $25,168 per couple annually. 2a. At $18,673 - $23,340 per individual and $25,169 - $31,460 per couple annually. 2b. At $23,341 - $28,008 per individual and $31,461 - $37,752 per couple annually. 3. At $28,009 or higher per individual and $37,753 or higher per couple annually. 8
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Insurance Types Affordable Care Act (Non-Medicare) – Pick the insurance that fits your needs from the Marketplace – Metal Tiers Tiers are assigned an “actuarial value” – Refers to the healthcare expensed the plan will cover – The higher the actuarial value, the lower the out-of-pocket cost 9
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Insurance Types Bronze plans will have lower premiums, but higher out-of-pocket costs (60% coverage) Platinum plans will have higher premiums, but lower out-of pocket costs (90% coverage) – Bronze Plan – Silver Plan – Gold Plan – Platinum Plan 10
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Premium Subsidies Available Premium cost subsidies will be available to people with incomes from 100% of the Federal Poverty Level to 400% of the Federal Poverty Level (FPL). Applies to silver plans only. Examples of 400% of FPL in Wisconsin: 1 member in family$ 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
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Insurance Types Commercial Insurance – Plan coverage varies widely in benefit design based on the type of plan 12
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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
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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
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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
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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
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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
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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
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Insurance Types Federally Funded Insurance How does Medicare Part D work? – Broken down into four parts 1.Part 1: Initial $310 deductible 2.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
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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
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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
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Manufacturer Coverage Some individuals may be eligible for direct coverage through the manufacturer based on financial needs 22
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Co-Pay Assistance Foundations Four of the main organizations that have funding for multiple myeloma 1.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
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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
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Typical Case Scenario – Revlimid® Cost: $9,000 - $12,000 per cycle 25 Deductible $262 Coverage $635 Coverage $635 Donut Hole $1759 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
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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
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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
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Questions? 28
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00/00/2013 thank you
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