Pharmacists can play a role in overcoming patients’ financial and personal obstacles to oral chemotherapy. In addition to appealing to the insurer for coverage, pharmacists can determine available assistance for patients, said Sarah Hudson-DiSalle, PharmD, RPh, at the Hematology/Oncology Pharmacy Association 9th Annual Conference.
Patients prescribed oral chemotherapy agents are often faced with large copays because these agents tend to be placed on specialty tiers. Underinsured patients may lack the financial ability to cover these out-of-pocket expenses. “We worry about these folks because they take on the characteristics of the uninsured patient,” said Hudson-DiSalle, specialty practice pharmacist at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio. “They start to skip doses at the end of therapy, they may split tablets.”
Most at risk are Medicare patients who do not qualify for low-income subsidies and have high copays that are in the coverage gap, and patients who have commercial insurance with high deductibles or limited coverage.
“You need to ask your patients what their prescription drug copayments are and [if the copayments are] drug specific [a high copay for only one medication or across-the-board high copays],” she said. If copayments are drug specific, the pharmacist can attempt to work with the insurer to get the oral chemotherapy agent on a different tier, such as a letter of medical necessity with supporting literature.
If the patient has a generally high copay, the cost may be ameliorated with manufacturer copay cards. Disease-based assistance, such as grants provided by nonprofit foundations, also may be available. Manufacturer patient assistance programs, which are medication specific, can be tapped as well.
“When you launch a new medication, it’s important to take a proactive approach,” she advised. “Meet with the pharmaceutical manufacturer representatives ahead of time” for coverage resources, patient assistance program forms, and discount cards. Gather information from clinics (ie, patient lists, prescriber and dosage information) and contact patients to find out which specialty pharmacy they use, with whom they are contracted, and their income level.
A structured program offers a long-term solution for patient medication needs. It has the potential to improve medication access, adherence, and continuity of care, said Hudson-DiSalle. It also offers the opportunity “to be a patient advocate on a state and national level to make a positive change for your patients,” she said. One such positive change is supporting legislative efforts for oral chemotherapy parity, which ensures equal coverage at equitable rates for oral and intravenous chemotherapy drugs. The Cancer Drug Coverage Parity Act (HR 2746) is expected to be introduced into the US House of Representatives soon.
Oral chemotherapy requires educating patients about the effects of food on the pharmacokinetics of the agent, said Robert Mancini, PharmD, BCOP, postgraduate year 2 oncology residency director at St. Luke’s Mountain States Tumor Institute, Boise, Idaho.
“It’s our job as pharmacists to assess the patient’s ability to handle these oral agents,” he said. Adhering to instructions may be especially difficult when patients are on combination drugs given with different instructions with regard to meals. In such instances, helping patients set up their food schedule may be as important as setting up their medication schedule.
“For those who work with dietitians, you may want to consider immediate referrals so they can step in and provide additional assistance,” said Mancini. —WK