Navigating Barriers for a Prostate Cancer Treatment: 2 Pharmacists, 2 Technicians, from 4 Locations
Wednesday 6:30 pm
Pharmacist (Large Academic Center):
Hi ladies. I hope this message finds you well. I’m in need of your expertise. A friend of our family has advanced prostate cancer. He is taking enzalutamide (Xtandi). He has decent insurance, but his out of pocket cost is $2700+ per month.
He was referred to a foundation for financial assistance, however he doesn’t qualify for help because his assets put him above the cap. Financially the family is relatively well off, but they can’t afford that kind of co-pay. I’m not aware of anything that might help him out, but I know both of you have extensive resources and plenty of ideas, so any guidance you could provide would be much appreciated.
Thanks.
“He has decent insurance, but his out of pocket cost is $2700+ per month.. they can’t afford that kind of co-pay”
6:52 PM
Hi ______! Good to hear from you! What insurance does he have? It looks like some form of Medicare and if that's the case that won't be his out of pocket monthly cost once he gets out of the Donut Hole.
Thanks Karen!
8:10 PM
Pharmacist: Thanks so much for your help. He has Medicare Advantage with Anthem Healthkeepers.
8:16 PM
Karen Eutsler:
Nice to meet you! I will check in to some information for you once I get back into the office and let you know what I find out.
FRIDAY 12:24 PM
I called Astellas about Xtandi. Income for 2 people is $50,730 and they do a soft credit check when turning in the application so no fin docs are required at the time of application. If the patient is truly over income, unfortunately, there is no appeal process.
Zytiga is another possible option through Johnson & Johnson. income qualification for 2 people is $67,640. There is an appeal process for them. If over income, the patient needs to send in a letter stating that there has been a change in income from what was submitted and/or a hardship letting them know that they cannot afford the medication (while including the copay amount) I hope this helps and you or the patient can certainly call me with any questions or concerns and I will be more than happy to help.
SATURDAY 2:47 PM
Jerilyn Arneson:
So the patient has a Medicare Advantage plan. I'm a certified Medicare Benefits counselor registered with SHIP in Virginia. If the patient consents, I can look him up in the Medicare database and do a benefits investigation. Every Medicare Advantage plan is different so each one will have a different copay depending on the Tier of the drug. Specialty drugs are Tier 4 and usually come with a $100 copay.
Officially "the Donut Hole" has been phased out although there is still a "coverage gap", the patient will now only pay a 25% coinsurance during the coverage gap instead of 100%. So Melissa is right in that he won't pay that $2700 monthly after meeting the $6350 catastrophic cap- we just don't know what he'll pay monthly up until then. The basic breakdown for prescriptions looks like this now:
Initial Coverage Period - This is the amount we don't know but should be $435 deductible + Tier 4 Copayment. Coverage gap - At $4020, the patient then pays 25% of the drug. Catastrophic cap - At $6350, the patient then should only pay 5% of the cost of Xtandi.
Since it's patient responsibility + plan responsibility to get into the coverage gap, he'll probably meet that within a month. Then it's patient's 25% responsibility only to get out of coverage gap, but again that coverage gap is only from $4020 to $6350 so he could meet that in 1-2 months.
The other option is that Senior Connections - Capital Area Agency on Aging in Richmond also has certified Medicare Benefits Counselors and can help him find out exactly what he'll owe per month. (804-343-3000). Then, there are 8 Independent Foundations (PAN, The Assistance Fund, etc) that cover enzalutamide copays for Medicare patients. Of course. they've all run out of money and it's only January. I've got a couple of ways that I receive notifications when funds are available and open up in these foundations. I can let you know as soon as one opens up. Several of them will retro back at least 60 days and even up to 180 days. Not sure if the patient is able to pay upfront for a month or 2 until one of these funds opens up.
Sorry if I've made it more confusing! They've made this so complicated. Feel free to call or email me if you want me to look into what he'll truly owe.
Sunday 1:39 PM
Pharmacist: Thank you ALL so much for your help. I’ll pass along the information to the patient!
The patient case above is something seen in offices daily. They often “Phone a Friend/Advocate” from another facility when we come up with no solutions within our four walls…