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Tips on Biosimilars: A Financial Advocate Perspective

TOP - October 2021 Vol 14, No 6 | Biosimilars - Value-Based Care

As biosimilars are being used more and more in cancer treatment, it is increasingly important that navigators and financial advocates be familiar not only with how they work but also how patients with cancer should go about paying for them, according to Angie Santiago, AA, CRCS-I, lead financial advocate at the Sidney Kimmel Cancer Center/Jefferson Health.

“In our role, how we can prepare for biosimilars is to make sure we’re in the know; I can’t stress that enough: knowing the care teams, the pharmacy teams, the billing teams, the manufacturing companies, and the reimbursement managers,” she said at the AONN+ 11th Annual Navigation & Survivorship Conference. “It takes a whole team to prepare your financial advocates.”

A biosimilar is similar to a generic drug, but it is not a generic drug. A biosimilar is an FDA-approved drug that is highly similar to another FDA-approved biologic drug, known as the reference product. Biologic drugs are made from living things like cells, tissues, or proteins, and include a wide range of commonly used anticancer drugs.

“Although our role is nonclinical, we still need to be in the know about any changes taking place in pharmacy care teams, prior authorization teams, and even manufacturing companies,” she said. “With our role being nonclinical, we aren’t part of the discussion of preferred agents as part of a treatment or therapy plan, but that should not mean that we aren’t aware of these changes; in order to fully assess a patient’s medical coverage and options to bridge the gap for their out-of-pocket costs, we need to know the medications that are being ordered.”

Tips for the Pharmacy/Care Team

According to Ms Santiago, the first step to getting involved is by “proactively requesting to be in the know.”

For any new infusion patient, she studies not only the patient’s insurance benefits, but also their diagnosis and actual treatment plan. She also noted the importance of financial advocates being included on drug validation groups.

“Within this last year, it felt like biosimilar drugs were just popping up left and right, and I didn’t have enough information about them,” she said. “I couldn’t look at a new biosimilar and automatically tell whether or not there was a copay program or a patient assistance program for it. And those are things that I need in my role to be able to really help our patients.”

In response to this realization, she went to her pharmacy manager and asked to be included in any communication sent out about new drugs or regimens. “And although sometimes it feels like I get too many e-mails now, it was worth it,” she said. “It keeps me in the know, and it keeps our team in the know.”

She also pointed to the importance of building a department task force and maintaining constant communication between the financial advocate and the pharmacy team. “We often see cancer centers wanting to switch patients from one drug to its biosimilar, so keeping in the know is the best way to let us better prepare for our patients,” she added.

Tips for the Authorization Team

According to Ms Santiago, depending on the cancer center, the financial advocates might also act as the authorization team. But no matter who makes up the members, when it comes to communicating with the authorization team, she advises staying in the know in regard to medical benefits checks, and more importantly, understanding that payer’s medical policy and guidelines.

For instance, UnitedHealthcare recently changed its preferred drug for some cancer treatments. “When the billing team has to put in the authorization for a new patient, and they’re putting in an authorization for a drug that we know the insurance company doesn’t prefer, then what are they really doing?” she asked. “You may actually delay that patient starting treatment because you’re delaying the approval process. So it’s really important in regard to the authorization team to keep up to date with insurances.”

If a physician puts in a drug order for a payer’s nonpreferred drug, it might save time to inform the care team of the high likelihood of the insurance company denying payment. But according to Ms Santiago, scenarios will arise in which the prior authorization attempt should still be made, and if that is the case, the billing team should be prepared with documentation on why the physician still wants to go forward with one drug versus the other.

Being proactive and networking with the insurance provider representatives for your cancer center’s top payers can also serve as an invaluable resource in terms of staying up-to-date on payer policies, she said.

Tips for the Financial Advocate

The financial advocates should do their research on new biosimilars in the field, not only when a patient is prescribed that drug, but proactively. Find out whether the manufacturer is new, or if it is a company with which the advocate has already worked, a relationship with that company’s field manager may already exist.

Financial advocates should conduct further research on copay program options and patient assistance programs, confirming whether these programs are offered to uninsured patients, insured patients without coverage for a certain drug, or for compendia-approved and/or on-label use only.

“These are all things that we need to be informed on, because it allows us to know how we can improve the patient experience and get them started on treatment as soon as possible,” she said.

Finally, utilize manufacturer assistance programs, she advised, and let them serve as a second set of eyes in conducting another benefits investigation. Use the manufacturer for copay programs, as well as for recommendations for foundation assistance for Medicare Advantage or Medicare patients.

“We should always be open to network with the field reimbursement manager and the manufacturer company,” she said. “They’re not trying to sell us a product, so to speak. So it’s good to keep in the know with them so that you’re always on the same page in regard to new indications and new insurance policy changes. And then of course, that benefits investigation is a huge help for us.”

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Last modified: November 12, 2021