Best Practices for Prophylactic Therapy in Hemophilia A - Episode 7

Financial Challenges Associated With Prophylactic Treatment for Hemophilia A

Anastasia Abramson, PharmD, MBA, outlines administration costs associated with prophylactic treatments for hemophilia A as well as other financial barriers from a specialty pharmacy perspective.

Jonathan Ogurchak, PharmD, CSP: I know that you guys have alluded a little bit to some of the financial aspects of treatments for hemophilia A. The economics behind that are slightly different when it relates to the prophylactic treatments as opposed to just the on-demand treatments. I’d like to talk for a few minutes now about some of those administration costs. Coming from the specialty pharmacy perspective, Dr. Abramson, let’s talk a little bit about that first. What are some of those hard costs to the pharmacy when it comes to dispensing those prophylactic treatments as it relates to supplies and things of that nature? How are they possibly passed onto the patients or the caregivers? Does that really impact some decision making when it comes to looking at prophylaxis as an option? I don’t know if you’re able to comment on that.

Anastasia Abramson, PharmD, MBA: Sure. There are, of course, costs to both the pharmacy and the patients with therapy. But in terms of cost to the pharmacy for administration, aside from your normal dispensing costs, I would highlight the labor costs associated with our specialized team. We have nurses, pharmacists, technicians, insurance verifiers, and fulfillment staff to fill the drug, as well as the packing and shipping fees of the refrigerated products. There are ancillary supply costs that roll in the per diem fees that we bill to the payers. And the supplies required do differ between the therapies based on route of administration. Your subQ [subcutaneous immunoglobulin] treatment with emicizumab [Hemlibra] is pretty straightforward. Swabs, needles, syringes, anywhere from 1 to 4 doses per month. This contrasts with the intravenous treatments that can require needles and syringes for preparation as well as butterfly needles, tourniquets, dressings, and then patients with ports on top of that. There are dressing change kits, saline, heparin, and so forth, and those things can really add up. In terms of the monetary cost, I’m not sure that there’s really that much of an impact to the patient. They’re not paying out of pocket for these items. However, it is a burden to receive such a big box full of so many daunting things, and especially for those patients that aren’t necessarily comfortable with administering IV [intravenous] [fluids] yet, it can be quite overwhelming and take up room in their home, which is definitely a concern that we hear as well.

Jonathan Ogurchak, PharmD, CSP: Staying on that topic of expenses, barriers, things like that, what would be some reasons for a specialty pharmacy to maybe reach out to a third-party payer for a patient? How often are those pharmacies connecting with payers as it relates to prophylactic products for hemophilia A? If you could comment on that, I’ll stick with you again, Dr. Abramson, if you don't mind commenting on that.

Anastasia Abramson, PharmD, MBA:No. It’s quite a lot. We can run into barriers with coverage as well as high out-of-pocket responsibilities. Thus, while hemophilia products generally are covered, most require prior authorization approval and, in some instances, high dollar overrides as well. Specialty pharmacies may reach out to the plans to initiate the prior authorizations or coordinate with the doctor’s office if we call it and it does have to go through them. However, depending on how long the authorization is good for, this is basically annual. Difficulty in obtaining the authorizations in a timely manner can also of course impact when the patient starts therapy. But some plans actually require an override on each fill, so for our prophy patients, this would mean contacting the plan every single month for prophy. Then, if they’re also getting on demand, which can be off cycle from the prophy dosing, if they’ve experienced a bleed or something, that might be an additional outreach to get those overrides put in place. It’s really important for us to track the refills on prophylactic therapy and coordinate with the patient in a timely manner so that he/she has an adequate amount of doses on hand while we work to obtain overrides, which can have a 24 to 48-hour turnaround time for approval. This was why I mentioned we do make proactive outreach to schedule those prophy deliveries. We don’t want the patient waiting until they have 1 dose on hand left to call us and then we’re running into the weekend with trying to get an override, so really [we] are just making sure that we’re timing all of that effectively. Sometimes authorizations or overrides are also for specific vials or NDCs [national drug codes], and then also for a specific number of total factor units for the dispense. If there’s some sort of change in stock, this doesn’t happen so much with emicizumab given the standard sizing of the vials, but on those factor products with the different lots that can have varying units and market availability, we do find ourselves reaching out on some off cycles there as well to get an override or have the PA [prior authorization] updated.

Transcript edited for clarity.