OncoLink

Drug Reimbursement

Julia Draznin Maltzman
The Abramson Cancer Center of the University of Pennsylvania

Introduction

Keeping track of medications can be challenging, especially for those who may already be taking medications for other conditions like high blood pressure, diabetes, or heart disease. The medications that cancer patients may need to take include chemotherapy drugs, pain medications, anti-nausea therapy, growth factor support, and even bone strengthening medications. One of the most important issues that surfaces is the financial drain that these medications may cause to the patient and their families. This topic of discussion seems very timely now as the new Medicare prescription coverage debate ranges on. I have explored several options for people experiencing financial difficulties and hope that this week’s news focus would assist some of our readers as they attempt to navigate through the peaks and troughs of their cancer care.

Senior Citizens

Unfortunately, it is always the senior citizens who have the most difficulties. Most people try to put away money for retirement, a nest egg, as it is called. Ironically, it is precisely this nest egg that works against us in the end.

Currently Medicare, the government health care plan for the elderly, does not cover prescription medications. So cancer patients with pain or nausea must pay for their medications out of pocket. When the financial burden is too great and they try to apply to an assistance program, they often find that they have too many assets to qualify. Their nest egg has backfired.

Shop Around

The first bit of advice, applicable to all patients, is to shop around. Not all pharmacies charge the same for similar medications. More surprising is the price inconsistencies within the same pharmacy chain but in different locations. A recent Consumer Report compared the price of five prescription medications, albeit not cancer drugs, prescription medications, none-the-less. They checked prices in over 100 different pharmacies and found that the best prices are either on-line or from mass merchants. Independent drug stores were the most expensive with supermarkets falling somewhere in the middle. For example, a consumer report study shows the average total cost for a thirty-day supply of only five commonly used drugs. These averages were collected from 130 individual merchants (8 web sites, 12 stores for each mass merchants, supermarket, and drug store chains, as well as 15 independents. You can view the comparison table in an article entitled Where to shop, how to saveon the Consumer Reports Website.

Ask for Generics

Generic drugs usually cost somewhere between 25%-50% less than their brand name equivalents. However, as a new generic drug hits the market it may not be substantially cheaper than the brand name. The price drops profoundly as other generics are approved and available for retail.

Use Vouchers

Physicians are unlikely to have samples in their clinics anymore. However, they may have vouchers or coupons that can be used in local pharmacies when purchasing medications. Asking for the vouchers is easy and may prove to be helpful.

Use mail order and buy in bulk

Another bit of advice is to use a mail order service whenever possible. Pharmacies charge all of us an extra "processing fee" or "filling fee" that goes to supplement the pharmacists and the technician’s salary. This fee is avoided if medications are purchased from a mail order in bulk. This does require advanced planning and having enough medications to get a patient through the time period it takes to receive them in the mail. On the other hand, this service usually requires a purchase of three months at a time so drugs that require frequent adjustments may not be practical for this sort of a transaction. However, this works well for medications that a patient may need on a regular basis such as anti-nausea medications that a cancer patient may take after each cycle of chemotherapy.

Use the AARP

Sometimes the AARP may have mail order medications at competitive prices. Alternatively, they may have information on potential credible and safe resources for getting medications less expensively.

Pharmaceutical companies

Recently pharmaceutical manufacturers have offered discount cards to be used for their products for Medicare recipients who have no other prescription coverage. These drug discount cards have no enrollment or annual fees and offer substantial (20%-40%) discounts on drugs manufactured by the participating company. One caveat, some cards demand proof of a low annual income. Applications for these cards are available either in local pharmacies or on the individual company websites. Patients bring these cards with them when they purchase medications in pharmacies and receive the discount upon payment.

GlaxoSmithKline Orange Card

Covers all drugs

Annual income below $30,000 for an individual and $40,000 for a couple

Lilly Answers (Eli Lilly & Co)

Covers all drugs except controlled substances

Annual income below $18,000 for an individual and $24,000 for a household

Novartis Care Card

Covers select drugs

Two annual income categories exist: $18,000 per individual and $24,000 per couple or $28,000 per individual and $38,000 per couple

Pfizer for living Share Card

Covers all drugs

Annual income below $18,000 individual and $24,000 per couple

Together RX Card

Covers select drugs

Annual income below $28,000 per individual and $38,000 per couple

Joint effort of a number of companies including: Abbott labs, AstraZeneca, Aventis, Bristol-Myers Squibb Company, GlaxoSmithKline, Janssen, Novartis, and Ortho-McNeil Pharmaceuticals.

These data were last updated 12/3/03 so more current information may soon be available. In addition, many of these plans may dissolve in 2006 when and if the Medicare prescription plan goes into effect.

We previously recommended that our patients apply to pharmaceutical companies directly to receive their product, if even for a "compassionate use" program. To date, multiple companies have generously given away millions of dollars worth of drugs to needy individuals. However, with the rising cost of drugs, demand exploded, and such offerings may not be financially practical or even viable for some companies. This is still an avenue to be explored as each case is reviewed individually.

Use your benefits

The Veterans Administration, a government hospital, offers free medication for American war vets. This resource too, is getting more and more scarce. There are constantly new requirements about whether or not the current condition under treatment is service connected and therefore covered entirely, or not service connected and therefore may be covered only partially or not at all.

Use your state

Each state may have its own particular medical assistance/drug prescription programs. I can speak for Pennsylvania that has what is known as the Pharmaceutical Assistance Contract for the Elderly (PACE) and the Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier (PACENET) programs. These two programs are funded by the Pennsylvania lottery and administered by the Pennsylvania Department of Aging. They offer comprehensive prescription drug coverage to older Pennsylvanians. These programs do not cover over-the-counter medicines, medical equipment, or doctor/hospital/clinic visits. There are no premiums or monthly fees to pay but a financial need must be identified. PACE requires a maximum annual income of $14,500 for an individual and $17,500 for a couple, where as PACENET is somewhat more generous and requires a minimum of $23,000 for a single person and $31,500 for a couple. Applications can be picked up from local pharmacies or on-line at www.aging.state.pa.us. However, this is state specific and may not exist in every state.

Conclusions

I hope that I have provided a few potential sources for medicine procurement that may help ease the financial burden that they impose. Patients not yet of Medicare age should consider all these avenues as well. Generic medications, buying in bulk and vouchers given in the office are applied universally to all patients. If finances allow, patients should purchase insurance plans that may offer some assistance in prescription medications. Every effort must be taken not to loose current health insurance and sometimes an expensive COBRA coverage may be economically worthwhile. Consider setting up spending accounts for medical expenses as these are usually pre-tax dollars. Those who can not afford insurance should apply for medical assistance programs known as Medicaid.

Buying drugs from overseas or even Canada may prove to be a risky proposition. There have been multiple reports of people getting bogus medications. Furthermore, these drugs are not regulated and their ingredients may vary from what exists in the US. In the long term, this route may prove to be a disservice to patients and their families.

I would like to extend a special thanks to Patricia Gambino, RN, MSN, who helped steer me in the direction of all the available resources in the research and writing of this article.