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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 Care
Lauren Marquardt, UW Pharmacy Student-Class of 2015
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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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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
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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
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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.
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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
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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
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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
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Insurance Types
• Commercial Insurance
– Plan coverage varies widely in benefit design based on the
type of plan
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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.
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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
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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
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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
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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
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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
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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%
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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
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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
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Manufacturer Coverage
• Some individuals may be eligible for direct
coverage through the manufacturer based on
financial needs
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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
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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
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Typical Case Scenario
– Revlimid® Cost: $9,000 - $12,000 per cycle
Deductible
$262
Patient has
not met $310
deductible
Coverage
$635
$2850-$310 = $2540
Donut Hole
$1759
Catastrophic
$ 143
$3704(47.5%) = $1759 $2877 (5%) = $143
$2540 (25%)= $635
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
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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/ByTopics/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
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Questions?
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00/00/2013
thank you