The oncology world is fast-paced and ever-changing, with new treatments entering the market rapidly. One of the fastest-growing treatment options is the use of oral oncolytics. With these new drugs comes a heavy price to pay at the pharmacy. Unlike traditional chemotherapy and immunotherapies administered in the outpatient setting and billed to the medical plan, patients receive these drugs through specialty pharmacies and use their pharmacy benefits. The pharmacy will collect the copay before the medication is dispensed, and the patient experiences the financial toxicity of cancer treatment immediately rather than waiting for a bill in the mail. Due to this, patient and financial navigators need to be aware and learn how to tackle the problem preemptively.
Pharmacy Technicians with retail experience can be of great value in this role. We know how the pharmacy system works and how prescriptions are billed. And we are familiar with copay cards and the terms they work under. When our patients are prescribed a new oral oncolytic, my first job is to conduct a benefits investigation to find out what portion of the drug cost the patient is responsible for. Then depending on what type of insurance they have, I look for funding. For commercial patients, a quick google search of the drug name and “copay card” will pull up the manufacturer’s website, and you can quickly locate the enrollment process.
To be efficient, I work with the patient to secure this doing most of the leg work. Most copay cards do not require any documentation or income verification and are obtained in a matter of minutes. For the uninsured or underinsured, the process is a little different as we usually pursue patient assistance programs or grants through various foundations. The underinsured patients are mostly Medicare enrollees whose out-of-pocket is 5% of the drug cost after the deductible is met. While 5% does not sound like a huge number, you have to keep in mind that tthe average oral oncolytic costs around $20,000 for one month’s supply.
My biggest resource for these patients is FundFinder.panfoundation.org. You can pick the disease state of your patient and see which funds are currently available. The PAN Foundation, Lymphoma, Leukemia Society, Patient Advocate Foundation or PAF, Healthwell Foundation, and CancerCares Foundation are the most commonly used funds. There will be a link to these foundations to help you navigate their website and enroll the patient. When the grants are awarded, the patient will be given a card to use at the pharmacy, much like a copay card.
However, these cards can be used alongside Medicare part D whereas traditional copay cards from the manufacturer cannot. When there are no grants available for a specific diagnosis, I go directly to the drug manufacturer’s website and look for patient assistance programs that they offer. Since most of these drugs are brand new, there are no generic alternatives, so patient assistance is available for almost all. There is a PDF enrollment form that you can print out and fill in with the patient, or some programs even offer an electronic form the patient can do on their own.
Some of the commonly used patient assistance programs used are Pfizer Oncology together for Ibrance, MyBeiGene for Brukinsa, Seagen Secure for Tukysa, and Novartis Patient Assistance Foundation for Afinitor. These programs are income based and only available to patients under 400-500% of the poverty level. Once enrolled, the medication is shipped directly to the patient each month at no cost until the end of the calendar year. A new enrollment form is required each year to determine continued program eligibility. This can save the uninsured patient potentially $250,000 a year and offer them a treatment they otherwise would never be able to afford.
These programs are continuously changing their eligibility requirements, so staying up to date is important. For instance, Johnson and Johnson (JJPAF) will not enroll any insured patients as of 2023. This is due to PBM changes in coverage. This affected almost all of our patients on Zytiga (abiraterone). For these patients, a few specialty pharmacies such as Onco360 and BioPlus have stepped up to the plate and assisted these patients. Staying on top of the new drugs and what patient assistance is available from the manufacturer is crucial to patient outcomes. Financial navigation with these drugs can be confusing and tedious but well worth it when a patient can start a new treatment at no cost or at an affordable price.
