Work closely with insurance companies to relieve financial assistance burdens and prior authorization requirements for patients.
With the cost of prescription medications rising each year, one of the most harmful results is cost-related nonadherence (CRN). Many socioeconomic factors contribute to CRN, including high out-of-pocket costs for medications, lack of health insurance, low income, and minority status.1 To understand how these factors play a role in CRN, it is critical to first understand the impact each has on patient access to needed treatment. By understanding these factors, pharmacy technicians can play a crucial role in removing some of these barriers for patients initiating treatment with high-cost prescription medications.
A cancer diagnosis, for instance, can represent an incredibly difficult time in an individual’s life. The overall treatment plan, as well as adverse effects and cost, is among many considerations a patient and family members may have to work through.
In 2020, an estimated 1.8 million new cases of cancer were diagnosed in the United States, with that number expected to rise in 2021.2 In 2020, the national costs for cancer care were estimated at $208.9 billion, which includes costs for medical services and oral prescription drugs.3 Some of the most expensive prescription costs by cancer type were breast cancer at $3.5 million, leukemia at $3.2 million, lung cancer at $1.8 million, prostate cancer at $1.7 million, and renal cancer at $1.3 million.3 The national costs are projected to increase to $246 billion by 2030, based on population growth.4 These high out-of-pocket costs are unattainable for most patients, even for families with 2 incomes. Whether the cause is related to inadequate or no insurance coverage or insufficient funding, these barriers often make it difficult for patients to begin treatment.
In addition to cost, ethnic and racial disparities play a role in CRN. The results of a National Health Interview Survey from 2006 to 2012 showed that among 10,998 cancer survivors, 1397 reported CRN. Among those older survivors, Black individuals were 2.64 times more likely and Hispanic individuals 2.07 times more likely than White individuals to report CRN. Younger, Hispanic survivors of cancer were 1.61 times more likely than White survivors of cancer to report CRN. Based on continual increases in the cost of prescription drugs, these findings support the importance of closely monitoring CRN in high-risk subgroups and offering them support services to promote medication adherence.5
Most drugs, as indicated by the third-party payer (TPP) in the specialty tier of a prescription benefit plan, may require prior approval—commonly referred to as prior authorization (PA)—that may be a drug access barrier for patients. PA is a therapy utilization management process employed by TPPs, aimed at controlling costs and managing drug safety.6 Select oral oncology medications may be alternatively billed through a patient’s Medicare Part B plan. There are 2 types of services covered under Part B: medically necessary and preventive services.7 In consideration of these factors, technicians often play a crucial role in obtaining PAs and securing other forms of financial assistance available to patients.
Technicians can submit PAs effectively and efficiently by providing clinical documentation—such as evidence-based literature and genetic testing, laboratory, and pathology results—to the TPPs to facilitate a successful, timely outcome. It is also important that technicians be trained to determine when parts of the submission process are not within their scope of practice and to seek further guidance from a practitioner. Additionally, there may be instances when a PA is denied and a technician trained in PAs can seek an appeal via the standard process outlined by TPPs, which may include an option for a peer-to-peer encounter between the health plan medical director and the prescribing physician.
In addition to assisting with the insurance portion of a patient’s treatment, technicians can help with removing the financial burden brought on by many prescribed treatment plans. There are many resources available to assist with these financial concerns, including commercial copay cards, foundation grants, free trials, manufacturer free drug programs, and voucher programs.
Co-pay assistance cards can only be used with patients who have commercial insurance. The cards do not have income requirements and typically cover most of or all the co-pay. However, there may be annual benefit limits. Trial cards or voucher programs are limited to 1 use per lifetime and do not have restrictions on whether a patient is insured or uninsured. They also have no income requirements and provide the patient with free medication to begin treatment immediately.
Technicians may also tap various foundations to assist on a patient’s behalf and obtain grants specific to a disease state. A patient’s eligibility largely depends on disease diagnosis and financial need, which typically is measured by national poverty levels. In addition, some foundations or grants may be closed for enrollment because of insufficient funding. Finally, when all options are exhausted, technicians may attempt to assist patients by obtaining free medications from the manufacturer. This scenario typically happens when available funds obtained are insufficient to cover the coinsurance or co-pay; no grants are available; the patient does not qualify for foundation or grant assistance; the patient does not have prescription drug coverage; the PA is denied; or it is required for compassionate, off-label use for a disease state.
Not all patients are approved for free medication through a manufacturer’s patient assistance program, because of eligibility being largely based on income. This should not deter technicians from pursuing assistance. They can further advocate for patients who have been denied an appeal by submitting a letter of financial hardship; providing financial documents including expenses, medical bills, and receipts; and including a letter of medical necessity from the provider.
Financial burdens and insurance barriers can be managed by skilled pharmacy patient advocates, often technicians, who work closely with insurance companies and understand the criteria required to obtain approvals. They can use resources available to them, such as co-pay cards, foundations, or grants, as well as free trial cards or medication from the manufacturer.
Jenny Peña, CPhT, is a pharmacy technician at Banner Health.