Help with navigating the high cost of specialty medications

Just as navigators help guide ships through uncharted waters, so does the Cape Cod Healthcare specialty pharmacy navigator program team by helping patients sort their way through the complexities of co-pays and high-cost specialty medications.

The program, which started about six years ago, has grown from assisting with the processing of approximately 100 prescriptions per month to between 500 and 600 prescriptions per month.

“Six years ago, our focus was oncology and infectious disease,” said Michael Anastasia, CPhT, program manager of retail pharmacy reimbursement. “Now, we do a lot more rheumatology, neurology, gastroenterology, addiction medications, along with some dermatology and orthopedics.”

Another change is the Specialty Pharmacy is now the preferred specialty pharmacy for the Cape Cod Healthcare employees’ insurance plan, which has contributed to an increase in the number of prescriptions the program fills, said Anastasia.

The navigators are three certified pharmacy technicians and include Anastasia, Stefanie Haen, CPhT, and Christina Vigneau, CPhT. They help with insurance approval for specialty medications, assist with finding financial assistance for high copays and interact with physician offices, insurance companies, drug manufacturers and charitable organizations.

The three pharmacists who review new prescriptions for dosing and medication interactions are Maria Michaud, RPh, James Citrone, PharmD and Mitch Summey, RPh.

Among the list of activities Anastasia, Haen, and Christina Vigneau, CPhT, perform daily are:

• Work closely with specialists and providers to fill out prior-authorization paperwork for insurance companies.
• Develop personal care plans for patients and follow-up with education, monitoring of treatment and support.
• Call patients five or six days before refills are due to ensure that patients continue to take their medications as directed.
• Research funding to help with co-pays and costs of the prescriptions.
• Work with patients’ providers to obtain prescriptions for an appropriate alternative medication when the brand isn’t covered.

Haen also goes to the Cape Cod Rheumatology office to assist staff and patients with the paperwork in obtaining coverage for medications and co-pays.

High Cost of Specialty Medications

Sticker shock can be an understatement when it comes to the cost of specialty medications. Anastasia said many oral oncology medications cost $30,000 to $40,000 per month. As high as that cost can be, the co-pays can also catch patients off-guard when they find out they can be $3,000 to $4,000 per month.

Some of the higher cost medications are Humira and Enbrel to treat diseases like rheumatoid and psoriatic arthritis, and Xtandi, Zytiga, Nubeqa that are chemotherapy drugs for treatment of prostate cancer.

The medications advertised on TV are frequently the most expensive, said Anastasia.

Vivitrol, a non-opioid injectable medication to treat addiction, is also costly.

“We look into funding to help with their co-pay before we call them, so we can tell them there are resources to help them,” said Haen, a specialty pharmacy tech.

“Some of the major pharmacies will send a six-page patient assistance program (PAP) application to the patient to apply for financial assistance through the drug manufacturer. They will have them fill it out to maybe get approved,” Anastasia said. “We fill it out with the patient and help them submit it.”

Resources for funding include manufacturer co-pay cards and charitable organizations that the techs can tap into to request help to try making co-pays affordable. They help the patient complete the paperwork to make it as easy as possible, said Anastasia.

Charitable organizations they contact include Patient Access Network Foundation (PAN), Patient Advocate Foundation, Cancer Care, the Leukemia & Lymphoma Society, the Health Well Foundation, and My Good Days.

Meticulous Research

While the process may appear seamless to patients, the process of filling out paperwork, interacting with physician offices, insurance companies and funding sources takes a lot of time and energy for the specialty pharmacy staff, who thoroughly enjoy helping their patients.

“There is nothing that feels better than being able to help somebody who has a debilitating or life-threatening disease get their medication,” said Anastasia.

Falmouth Hospital patients can be referred to the specialty pharmacy navigators at Cape Cod Hospital for assistance with their financial and insurance needs.

Once insurance approves payment for the specialty medications, the navigators working through the Cape Cod Hospital and Falmouth Hospital retail pharmacies will have the medication available for the patient to pick up, have it delivered to their specialist or mail it to the patient for administration at home.

Further information is available by calling the specialty navigator team at 508-862-5905, Monday through Friday, 8 a.m. to 5 p.m. A pharmacist can be reached at the same number after hours to answer any questions and provide support.