Pharmacist Keys for Unlocking Medication Access
Steph’s Note: This week, we’re going to discuss a topic near and dear to my pharmacist heart: medication access.
I say near and dear now, but I have to be honest… Medication access wasn’t really something I thought a whole lot about when I first started practicing pharmacy a little over 10 years ago. (This probably horrifies a lot of you who have more recently joined the profession, but yes, it’s sad, but true.) Honestly, I remember doing the occasional enoxaparin discharge counseling, and the script was sent to the desired pharmacy. But did I ever check price on that script? Make sure insurance covered it or help complete a prior authorization? Consider how or when the patient would be able to make it to the pharmacy to pick up their new script for continuity of doses after leaving the hospital?
Again, sadly, not so much. “Transitions of care” was a relatively new buzz word concept at that point, and as a profession, it was like we were just starting to consider what happened for our patients after they left our direct care.
These days, I work as a clinic-based pharmacist under the umbrella of specialty pharmacy, and let me tell you, transitions of care and medication access are (no lie) probably 90% of my daily job. Oh how the tables have turned!
Working as part of specialty pharmacy certainly heightens the need and awareness to pay attention to medication access, but really, this isn’t an exclusive concept to just the specialty medications. Even some of the old-as-dirt medications can be pricey depending on a patient’s insurance plan, or lack thereof, and it’s imperative for us as pharmacists to know how to navigate ensuring patients are able to obtain the medications prescribed for them.
“The most thoughtful, evidence-based pharmacotherapy plan doesn’t mean a hill o’ beans if a patient can’t get the meds!”
Not only does the specific medication not really matter when talking about the importance of understanding access resources, but it also doesn’t really matter what your current - or planned - pharmacy practice setting is. Unlike what I used to think, even working in a hospital does not absolve you of this requisite knowledge! We all have to know at least a little about insurance and assistance.
Keeping this in mind, we’re going to take it back to the beginning of what medication access means. Then we’ll discuss a bit about insurance and types of assistance.
What is Medication Access?
There are undoubtably multiple definitions for what medication access entails, but this how I’ve come to think about it over the last couple of years.
Medication access is everything that occurs in between the point of prescribing and the point of physically obtaining a medication. I’m not necessarily just talking about the first prescription being picked up either. I mean a patient starting with the first doses and continuing to adhere to their chronic therapies.
Ensuring medication access requires a number of steps and understanding various resources, particularly as relates to the following:
Insurance coverage
Out of pocket costs
Communication
Transportation
Let’s take each of these pieces and break them down just a bit further.
Understanding Insurance Basics
So disclaimer… I am not an insurance expert! I learn something new every day about this topic. This section is not meant to be a tell-all on understanding every type of insurance. Rather, I want to impart some tips about parts of insurance that I encounter most when it comes to access issues, which will hopefully increase your baseline knowledge. Then you can continue to learn on your own!
Alright, now that that’s out of the way.
The first step that I take when I receive notification that a patient will be starting a new therapy is to check their insurance status. (That’s right, I check this even before assessing their clinical factors. A medication may be a perfect clinical fit for a patient, but if we can’t get it in their hands, it doesn’t really matter how clinically perfect it is.)
Some patients do not have any insurance coverage at all, which takes us down a separate path in the medication access system (more later). But for those who do have insurance coverage, it’s important to take note of what type.
A Slight Rabbit Hole into Types of Insurances
Most people either have some type of government insurance, including Medicaid, Medicare, or military Tricare, or a commercial insurance like Anthem, Aetna, United Healthcare, etc. Medicaid is the nation’s healthcare coverage program for eligible adults with low income, children, pregnant women, some elderly adults, and people with disabilities. Medicaid programs are executed by the states according to federal requirements and are funded by both government entities. Social workers often facilitate a person’s enrollment into Medicaid, but it’s important for pharmacists to at least know where to point patients to start this process. This page lists all 50 states with links to information about how to apply for Medicaid.
Medicare is the government-provided insurance for those over 65 years old, certain younger individuals with disabilities, and those with End Stage Renal Disease (ESRD). While Medicaid is typically low or no cost coverage for qualifying services, Medicare is (of course) more complicated than this. The main parts of Medicare that you should be aware of are A, B, and D.
Part A helps with inpatient admission expenses (hospital, skilled nursing facilities, etc).
Part B assists with outpatient and preventative services, doctors’ services, and medical equipment.
Part D is prescription coverage.
(Image)
Patients have the option of signing up for original Medicare, which provides parts A and B (for a premium for B). This is the “red, white, and blue” card you’ve probably heard people talk about. Some people pay to add a Medigap policy (aka a Medicare supplement) to original Medicare to help with out of pocket costs not sufficiently covered. Part D can also be added to original Medicare for a premium.
The other option for patients is to enroll in a Medicare Advantage plan, which, much like your internet and cable company, bundles all services into one package. These plans include parts A, B, and D, and they may also have other coverages, like vision or dental. Coverage through these plans is updated on an annual basis, meaning details - like the drug coverage - can change each year. Patients need to be cognizant of their annual insurance open enrollment window so that they can check their prescription coverage and change plans if need be.
So just to emphasize these very important points… First, patients must actively enroll in Medicare part D prescription coverage whether they’re choosing original Medicare or a Medicare Advantage plan. This means that it is an extra step and an additional cost to have prescription coverage over age 65. And second, even medical coverage from parts A and B is not 100% and can leave patients with significant out of pocket costs.
As a pharmacist, you will absolutely encounter Medicare part D issues with prescription coverage. But you may also encounter A/B issues if your patients are receiving infusions or other medications specially categorized into part B coverage (e.g., some transplant medications).
I don’t know how many times I’ve read in a provider communication to a patient, “You have Medicare, so your out of pocket costs should be next to nothing.” FALSE!! Please do not fall into this trap of thinking Medicare offers the same benefits as Medicaid just because they are both government-administered programs.
Determining the type of insurance also may not be as simple as looking at the insurance name. In many places, some of the commercial companies are also contracted with the state to administer Medicare or Medicaid plans, so you may see coverages listed like “Anthem Medicaid” or “United Healthcare Medicare.” These are still Medicare and Medicaid plans, but they may have different qualifications and benefits than the straight government-provided plans - even down to the county in which the patient lives.
To make things even more complicated, there are also some programs that offer dual Medicare + Medicaid programs for qualified individuals, such that the Medicaid acts as a secondary insurance to pick up remaining balances after Medicare has paid its portion.
$0 copays for active duty military service members and the ability to fill locally when needed, yay for access! (Image)
The last major government-administered insurance is Tricare, which is the coverage provided to current and former members of the US military, as well as their families. There are several Tricare plans available based on an individual’s needs and military status. With regards to prescriptions, Tricare has now contracted with Express Scripts for pharmacy management. Members can fill their medications at military pharmacies, Express Scripts Home Delivery pharmacy, or at civilian pharmacies, although the out of pocket costs to Tricare patients increase with each of those facilities.
So there’s a financial incentive for these patients to fill with military pharmacies when possible, with the exception that active duty military personnel have a $0 copay at any pharmacy. Of note, there may also be limits on how many times a maintenance medication can be filled at a civilian pharmacy before requiring transfer to either a military pharmacy or the Express Scripts Home Delivery option.
Long story short, the good news is that our active duty military and veterans can obtain immediate fills at a local pharmacy if needed when the military and mail order pharmacies can’t fulfill the script in a time-sensitive manner.
On the other hand, commercial insurances are often paid for by individuals or offered by employers to employees as part of a benefits package. If chosen outside of the context of a job, people may have the freedom to shop for the best plan on the Healthcare Marketplace (aka the “Exchange”). On the other hand, if working within the confines of an employer benefits package, they may have more limited choices in terms of coverages.
Insurance Financial Milemarkers
Much like we described for Medicare with different parts providing medical versus pharmacy coverages, most commercial insurance plans also split benefits according to medical versus pharmacy coverage. Management of the pharmacy portion for both government and non-government plans is farmed out to a PBM, or pharmacy benefits manager, to make determinations of coverage and track expenses. So for example, a patient with Anthem insurance may have determinations of coverage made by IngenioRx rather than Anthem itself because those 2 entities have contracted with each other.
Many insurances also function based on the idea that a patient must meet certain thresholds to take advantage of their plan’s benefits. This is where those terms - deductible, co-insurance, and out of pocket maximums - enter the scene. The deductible is the amount of money a patient must pay 100% on their own for qualifying expenses before insurance will start kicking in to help. People can choose from low deductible plans, meaning they shell out less before insurance starts helping, or high deductible plans, meaning insurance doesn’t start helping with costs until the patient has shelled more out of pocket themselves.
The unexpected isn’t fun to begin with, let alone when you add in an 1100 pound animal. And yet, we still do it… #horsecrazy
As you can imagine, low deductible plans require higher insurance premiums but may be better for people who know they’re going to have a lot of medical costs each year. On the other hand, high deductible plans are cheaper on the premium front but can be useful for people who aren’t expecting to have major medical costs that year. Of course, it’s a gamble because sometimes you incur medical costs you didn’t expect…
Once a patient meets their deductible, usually what comes next is the period of co-insurance. This is usually expressed in percentages, such as 70/30, 80/20, or 90/10, and what it means is that insurance will pick up either 70, 80, or 90% of the incurred eligible costs. This leaves the patient to pay anywhere between 10-30% of the costs, depending on the plan.
This co-insurance period continues until the patient reaches their out of pocket maximum for the year, at which point, the insurance plan will pay 100% of qualifying and approved costs. Some patients may reach their out of pocket maxes in February if they have a lot of medical bills, whereas others may reach it in November. Or, they may never reach it in a given year. High out of pocket plans are usually cheaper for patients (less risk for the insurance companies), whereas lower out of pocket plans have higher premiums.
In addition to considering these thresholds, it’s also important to consider whether a service or the rendering provider is in or out of network with the insurance plan. Insurance companies contract with certain providers such that they are part of the network, making costs for patients lower. However, out of network services will usually result in higher out of pocket costs for patients. For example, their co-insurance percentage for in network services may be 90/10 with an out of pocket maximum of $5000, but then their out of network co-insurance could be 70/30 with a higher out of pocket maximum. The idea is to try to keep patients going to contracted providers to keep costs down.
Now through a lot of this section, we’ve been talking about “qualifying” services. This is because not everything a patient is prescribed, medication or otherwise, may be considered a covered or necessary therapy.
Determinations of Prescription Coverage by Insurance
With regards to medications, all insurances, including both government and private, function based on a formulary, which is the list of preferred covered medications. It’s important to note that “covered” here does not necessarily mean 0% out of pocket cost for patients! As discussed above, there are often particular thresholds that patients need to meet in order to get to 100% coverage, although pharmacy benefits may stray from the afore-described co-insurance model to a copay model. This is where there are various tiers of how preferred a medication is, with each tier requiring a different flat payment from the patient.
For example, a tier 1 preferred medication may cost the patient $10 per month’s supply, whereas a tier 5 medication could be $150 per month. Each plan has different requirements for how and whether these expenses count towards any out of pocket maximum for the year.
Having a “covered” medication also doesn’t necessarily mean that the insurance company will automatically pay their part for the patient to obtain the medication. It just means the insurance company has created a list of the medications it would prefer patients to use based on disease-state evidence, contracting, and expenses.
Ok, now that we have some of the basics defined, we can return to next steps for our patient to obtain their new medication. As we just mentioned, insurance companies want to ensure that a prescribed medication, especially those of the expensive or specialty varieties, is appropriate and expected to benefit a person. Understandably, they don’t want to pay for a treatment that isn’t expected to help or for which there isn’t some sort of evidence of failure of more established, less pricey alternative. This patient screening is accomplished through a process called prior authorization (PA).
Prior authorization entails submitting a request to insurance for a particular therapy, along with supporting documentation for an individual’s medical necessity and the published clinical evidence. Clinicians at the insurance company then review this information to determine whether or not they agree the therapy is warranted and appropriate. This process can take several rounds of submissions and can occur either electronically or telephonically.
A PA is usually initiated either online or via the phone by the pharmacy that receives the prescription, but it almost always requires the involvement of the prescribing provider’s office given the need for clinical documentation and rationale. Once submitted, it can take anywhere from hours to a couple of weeks to receive a determination of coverage from the insurance company. They will either approve or deny the request. If approved, grand! Move on to cost (because remember, the cost may not be 100% covered). If denied, boo. On to the next steps, which usually includes a decision of whether or not to appeal the denial.
In their denial communication, insurance companies include information about how to appeal the original decision. This appeal and any supporting documentation is sent back to the same insurance company for review. Alternatively, insurance companies may offer what’s called a peer-to-peer review, which involves a physician who works for the insurance company speaking directly with the prescribing provider to hash out patient case details and rationale for the request. Determinations from appeals can take ~30 days, although peer-to-peer determinations are often much quicker.
If the appeal is STILL denied…after you’ve screamed in frustration, you may have the option of pursuing an external review. Unlike a straight appeal or peer-to-peer, this external review involves submitting patient materials to a 3rd party company - not the same insurance company. This 3rd party reviewer usually makes a determination within 60-90 days of receiving the case. If approved, woohoo! If denied, then you’re basically SOL on getting insurance to pay any portion of the therapy costs, and the team will either have to switch gears and pivot to a different therapy OR find an alternative way to pay for it.
Your face, when you receive notification of the expected turnaround for an insurance determination. (Image)
Now let’s stop for a moment and just take this in. We’re so used to thinking that if a medication is prescribed for a patient, they’re going to start it in a pretty reasonable time frame, right? They just have to get to the pharmacy or the infusion appointment, and voila, it’s all good.
But holy cow, we’re talking it could take up to THREE MONTHS for a determination on an external review!! What’s happening for the patient in the meantime? Are they clinically stable enough to tolerate that kind of delay in therapy, and should you continue to engage with insurance or abandon ship for a less optimal therapy that the patient can start tomorrow??
This is also why it’s so important to communicate with providers the status of the patient’s PA and access issues. They may also be thinking their patient has started and is benefitting from a particular therapy within days to a couple weeks after their office visit together, when in reality the patient is remaining UNTREATED for months on end. They likely have some thoughts about how long they’re willing to gamble their patients’ health based on a particular case, and they can help to make those decisions about timelines.
At this point, we either have an approved or denied PA for our new patient’s prescribed medication. In either case, the next step is to consider out of pocket costs for the patient.
Strategies to Reduce Out of Pocket Medication Costs
Once a PA has been approved, that doesn’t mean the story is over. In fact, sometimes the story has just begun! It’s time to run the claim through the system and see what kind of copay returns for the prescription.
If the medication is too expensive for the patient, it’s time to pull on your bootstraps and get back to work. We have resources available to help lower these costs!
Manufacturer Copay Assistance
The first option I consider is whether there’s a manufacturer copay assistance card available. These are discount cards provided by manufacturers for patients who are either uninsured or underinsured by commercial insurance, depending on the specific program characteristics. Of note, patients with government-provided insurance are basically ALWAYS ineligible for these cards, which means that those Medicare patients who have to meet financial thresholds to get to full coverage will not receive assistance from these copay cards.
Bummer, but c’est la vie.
The other caveats about these cards are that they’re usually only for brand name medications AND they also have annual maximum amounts allowed. For example, in my world of specialty pharmacy, many of the oral medication manufacturers offer brand name copay assistance cards with an annual max benefit of $20,000. Some card programs specify how much of that $20K is allowed to be used each month whereas others leave it as an annual limit, in which case perhaps a patient may use $5000 one month to pay their high deductible early in the year and then only need $400 monthly from then on until they meet their plan’s annual out of pocket max.
These copay cards usually function like “secondary insurance” and are applied in the pharmacy dispensing system after the patient’s actual primary insurance has already done its part. In order to make them work, you usually need to have 4 items of info (much like a pharmacy benefit insurance card):
ID#
RxBIN#
RxGroup#
PCN#
It’s important to remember that many manufacturers phase out these copay card programs when generic versions of their drugs are approved. Even if the copay card still exists for a brand name medication after a generic becomes available, the copay assistance provided by the manufacturer program will often be insufficient to cover a patient’s costs. This is because the brand name drug becomes a non-preferred formulation when the insurance company updates its formulary to include the generic, and even if you work a miracle and get the brand medication PA approved after rounds of appeals, the copay after insurance often exceeds the maximum allowed amount from the assistance program.
Let’s check out an example.
This scenario has frequently happened for many of my patients with multiple sclerosis after the approval of generic dimethyl fumarate in 2020 (previously only brand Tecfidera). Prior to last year, patients were often obtaining brand name Tecfidera for $0 out of pocket costs/month after insurance PA approval and manufacturer copay assistance. Now, given most insurance companies have hopped on the generic train to lower their costs and there isn’t reliable copay assistance for the multiple generic products, many patients are ironically encountering larger out of pocket costs for the generic version than they were for the brand! So the generic has often proven less costly for the insurance company… but more costly for the patients. This is leading to patients jumping ship to a different brand name medication that still has dependable manufacturer assistance, which in turn means the insurance companies are back to shelling out more money for a brand name product!
So that formulary change to generic has backfired for multiple plans. And it certainly isn’t helping to shift to lower healthcare costs overall. Hopefully this will be reassessed with next year’s contracting…
One example of an insurance plan’s copay accumulator program. (Image)
If we’re talking about copay cards, we also need to have a moment for a relatively new kid on the block: copay accumulator programs. These are specific regulations imposed by insurance companies on how copay card assistance may be applied to patients’ out of pocket costs through that plan. The goal of these programs was to incentivize patients to choose healthcare options wisely and to consider choosing lower cost alternatives. For insurance plans that haven’t imposed these accumulator regulations, it doesn’t matter whether the patient, the patient’s cousin, or the manufacturer is paying money towards the medication out of pocket costs. Any money paid can be used towards the patient’s annual deductible and out of pocket maximums.
On the other hand, many insurance plans have started instituting these copay accumulator programs as recently as this year. These programs seek to ensure that only the money that actually comes from the patient’s pocket is applied to their deductibles and out of pocket maximums. So the assistance provided by manufacturer copay cards no longer applies towards the patient’s out of pocket plan costs. The patient will still benefit at the pharmacy counter from the copay card, but they do not make the headway on meeting their deductible that they used to.
So what’s the big deal about this, you might ask? The patient should always be planning to pay their deductible regardless of whether they have copay assistance. Well, that’s true… But what we’re seeing is that after months of receiving copay assistance in a given year, if and when the patient exhausts their manufacturer copay assistance prematurely, the patient then is hit with their full deductible all at once from one medication fill. This large unexpected expense has caused some patients to have to change medications altogether, often to an option that still has manufacturer assistance available.
The other tricky part is that an insurance plan’s participation in a copay accumulator program is not always readily apparent. Clinics and even dispensing pharmacies may not be able to tell off the bat whether funds provided by the copay cards will apply to deductibles and out of pocket maximums. Long story short, it’s very important to advise patients to call their insurance companies’ member services lines to inquire about whether their plan is part of a copay accumulator or not. If the plan does have a copay accumulator program, then close scrutiny about whether manufacturer assistance will be exceeded within the year is important to try to help avoid the big, all at once out of pocket charges at some point later in the year. Patients should also be advised to pay close attention to their explanation of benefits reports to ensure they know where they stand with their financial thresholds when doing any medical planning.
Alrighty then. That’s the long and short of copay cards. So what if those still aren’t sufficient, or you just plain can’t get an approved prior authorization through insurance?
Patient Assistance Programs (PAPs) for Medications
This is where patient assistance programs may be able to step in. Again, often for brand name pricey medications, patient assistance programs (PAPs) can be useful to use when patients are uninsured or underinsured. Unlike copay assistance cards, PAPs may consider patients with government-supplied insurances (like Medicaid and Medicare) eligible if they meet the program requirements. This can be a huge bonus!
There is a wide variety in the stringency of these manufacturer PAPs. Some may only require an attestation from the patient about their household size and income, whereas others may require documentation and proof of these pieces. Some require documentation of denied PAs and appeals, while others want a letter from the providers’ office, explaining the unaffordable nature of the therapy and previous steps taken to try to increase affordability. Some will only consider an FDA-approved use of the medication to be eligible for free drug assistance, whereas others will assist even with off-label uses.
It’s imperative to either know who on your team manages applications for these types of programs or to become familiar yourself with program requirements. It’s also very useful to have contacts at each PAP program who you can call if you have questions or need assistance with an application.
Like PAs, these PAP applications can take weeks to months to get a final determination, so it’s necessary to make sure providers know about any delays in therapy initiation! Also, if approved, don’t forget to communicate that approval to the correct departments for a couple reasons:
Without that communication, the assistance may not be correctly applied to any bills incurred.
Approval of free drug may require obtaining the medication from a special pharmacy or location, which could affect what stock is used for dispensing doses. It may also mean ensuring a prescription is routed to the correct pharmacy for processing.
Many (if not most) PAP approvals are have expiration dates, so someone’s going to have to place a reminder to work on the reassessment and renewal of assistance to avoid future gaps in therapy.
In addition to the possibility of manufacturer-sponsored PAPs, there are also third-party PAPs that may be able to assist with supplementing partial medication expenses. These are also considered foundation or grant funds and are often disease-state based. Fund availability fluctuates, so it’s important for patients to check websites frequently and/or call the programs to check for fund availability. Examples of these can include HealthWell Foundation, the PAN Foundation, and The Assistance Fund.
An incredibly useful website for learning about available discount or PAP programs is NeedyMeds. While not necessarily 100% inclusive, it certainly can give you a leg up on investigating assistance programs. Searches are based on drug name, and from there, it’s up to you (or the patient) to sift through the options.
So what if a patient doesn’t qualify for a copay assistance card (or there isn’t one available), they aren’t eligible for a PAP (or there isn’t one available), and they STILL have a ginormous out of pocket expense?
Drug Discount Coupons and Programs
At this point, I often turn to GoodRx. This site is a repository of drug discount coupons as contracted by specific pharmacy locations. Pure and simple, GoodRx coupons bypass insurance, meaning nothing paid by the patient after one of these coupons goes to their accumulators and it doesn’t matter what/if a patient has a particular type of insurance. Anyone is eligible. It essentially provides patients with a cash price for their medication.
Is finding a GoodRx coupon for every one of a patient’s medications worth it, especially if each coupon is good at a different pharmacy in town? (Image)
Not every medication is available, and not every pharmacy participates with GoodRx, so each patient and medication requires an individual search on the site. (For those of you working inpatient, downloading the GoodRx app to your phone may help if you get in a pinch at the point of discharge!) Additionally, there’s no guarantee of continued discounts with GoodRx, so what’s here today as a discount may be gone tomorrow. Finally, another downside to this program is that it kind of encourages pharmacy shopping…
You’ve heard of doctor shopping, which is the term that refers to patients intentionally seeking out a prescriber who will give them scripts for the medications and doses they want. Well, pharmacy shopping means patients choose to fill their prescriptions at whatever pharmacy offers them the best price. So quite literally, patients can end up with active prescriptions at numerous pharmacies. You already know the nightmare of trying to encourage adherence and monitor for drug interactions when all the info is in one place. Now multiply that times 5 pharmacies (or more!), and you can imagine the nightmare that is pharmacy shopping. Not to mention the headaches this creates for medication histories!!
So my advice is to use GoodRx judiciously…and only in situations for which there is no alternative. I also wouldn’t consider it a reliable, long-term medication coverage source.
Another affordability option, especially for many generic medications, is to check local pharmacies for savings programs. Pharmacies like Walmart have their $4 list that doesn’t require any sort of joining fee, whereas others like Walgreens offer a “savings club” that can be joined for a fairly nominal fee to take advantage of a decent array of savings on 30 and 90 day supplies of common medications.
A last thought is to search for any local charity care provided either by a medical institution or pharmacy. For example, some of the larger medical center organizations offer financial assistance for services rendered at their locations. These are usually fairly strict programs with more rigorous application processes, but for folks who have exhausted other avenues and can obtain their medication at the medical center-based pharmacy, perhaps this application can offset costs after insurance - or in case insurance doesn’t exist or pay.
So at this point, we’ve checked insurance, submitted for a PA and received a determination, and worked on ensuring out of pocket costs are viable for the patient. What’s next? Making sure everyone knows the plan.
Communication throughout the Medication Access Process
The fact that effective communication is necessary for the medication access lifecycle isn’t exactly a big whoop-dee-doo surprise. But it’s so important and there are so many aspects of it that it still is worth mentioning!
Let’s break down the above medication access process into its communication pieces. Thus far, it has involved communication of…
the new prescription from the provider to the patient,
the new prescription from the provider to the staff responsible for submitting a PA, whether that is a pharmacist, pharmacy technician, or other staff,
the prescription and any supporting clinical documentation from the provider’s office to the insurance company to start a PA,
the need for a PA from the pharmacy back to the prescribing provider and the patient,
the outcome of the PA from insurance back to provider and patient,
the need for any additional steps or documentation to complete an appeal or external review from insurance to pharmacy to provider and back,
the outcomes of any of these additional authorization processes from insurance to provider and patient,
the copay after insurance from pharmacy to clinic staff and patient to determine affordability,
the need for copay assistance or patient assistance from pharmacy to manufacturer programs, patients, and providers and what actions are required of each,
the enrollment of patients into assistance programs with billing entities or pharmacies or into REMS programs,
the explanation of how the assistance program works with patients,
the need for a prescription to be re-routed by a provider to the assistance program’s preferred pharmacy,
the need to cancel the original prescription at the first dispensing pharmacy,
confirmation by the patient that they have medication in hand (woohoo!),
how to use that medication and what to expect from pharmacist to patient,
the need for staff follow up after a certain time period to ensure any PA or assistance renewals are completed, and
any downstream clinical or billing issues from the patient to the provider or other clinic staff.
Holy cow. I’m exhausted just reading that list…and I’m the one who wrote it. I didn’t do it to be pedantic, but I think it helps to illustrate just how many hands are in the pot on a single prescription - especially those that are expensive and a little harder to access. Put another way, here are the entities who may be involved in each med access case:
Patient
Provider
Clinic pharmacist
Clinic pharmacy technician
Clinic nurse coordinator
Dispensing pharmacy staff
Insurance company representatives
Manufacturer copay and patient assistance program representatives
Manufacturer support and REMS programs
Clinic billing staff
Talk about herding cats! Not to mention we’re communicating across various platforms, including the medical chart, fax, phone, email, Mychart, secure messaging portals, etc. That’s a lot of folks and platforms to keep straight to ensure a patient is able to start a medication in a timely, cost-effective manner! And guess who is often poised in the center of it all, keeping tabs on status changes and communicating with the other entities…
Pharmacy to the rescue! (Image)
You guessed it - the pharmacy team!
So if you haven’t already, now’s the time to start practicing writing concise but thorough chart notes and emails. Get comfortable with cold-calling people, both patients and companies. Don’t be afraid to push the wrong button in a phone tree. Trust me, you can always get back to the previous level - even if you have to start back from scratch.
Also, try to tackle cases in which the patient’s first language is something other than English! Being able to navigate the above steps is a hard enough task when speaking directly to a patient in English, let alone getting all the updates and information across through an interpreter. It really takes practice to get comfortable with metering your sentences and not losing your train of thought while the interpreter is relaying your previous thought.
Effective, clear, and clean communication, both written and verbal, is essential to being a useful pharmacist. (All those interview questions and rotation assessments that have to do with communication really do have a purpose!)
So now everyone’s on the same page about the medication and affordability, and it’s time to physically get the prescription to the patient.
The Impact of Transportation on Medication Access
Just like communication, this isn’t necessarily the most mind-blowing facet of medication access. But there may be tidbits here that you haven’t yet considered about the impacts of transportation on patients’ abilities to obtain and take their medications.
Of course, there’s the obvious. For patients filling medications at local pharmacies, they need to have transportation in order to pick up those prescriptions. For patients receiving infusions, they need a reliable means to make their appointments on time. Otherwise, no one’s getting medication into their body. But let’s take it a step further.
There’s also the aspect of mail order pharmacies and transportation impacts. These pharmacies need to have reliable, efficient transportation to ship or courier medications to patients or places of administration. Prior to last year, we probably took our mail system for granted. However, in 2020, on more than one occasion, I received a phone call from a patient asking whether they could use their refrigerated medication if the ice packs were all melted on arrival.
From even just a single day delay in shipment, when flights and ground transportation staffing issues arose, patients encountered medication access issues. Some of these patients even had gaps in therapy due to the time it took for them to call the pharmacy and arrange shipment of a replacement dose.
Then there’s the aspect of infusion medications needing to be shipped from a mail order pharmacy to a place of administration. What happens when that shipment is delayed? The patient’s appointment has to be rescheduled - if we can reach them on short notice - and if not, then they may actually drive hours to an appointment for which we have no medication.
Very much no bueno breaking that news. And if they’ve booked a local hotel for the night after their infusion because they have such a long drive…
Yeah, those calls aren’t fun.
But it’s the unfortunate reality of working within a system that relies on multiple modes for obtaining medication. Sure, it would be nice if we could always use institutional stock already on hand for patients’ doses, but sometimes that is just far more costly for insurance (and therefore, for the patient).
Finally, even though we rely heavily on social workers to help navigate patient transportation issues to appointments or even locally to run errands like picking up prescriptions, it’s still helpful to at least have an awareness of some of the transportation resources available in your area. For example, some Medicaid patients have transportation benefits that allow them to pre-order a cab ride for medical appointments or needs.
The tl;dr of Medication Access
I warned you that this is a topic near and dear to my pharmacist heart! Hopefully I haven’t rambled too awfully much… But my goal for this post was to highlight at least some of the skills and steps required for pharmacists to ensure medication makes it from a (to be blunt, theoretical) prescription to a medication in the patient’s hands - without breaking the bank account.
Medication access is constantly evolving, and you can never know it all. But you can familiarize yourself with some of the key basics to be used in any and all pharmacist practice arenas!