How Can Pharmacists Help Patients Lower Medication Costs?

In 2013, the price of an old, yet commonly used antibiotic—doxycycline—increased as much as 2500%, to between $210 and $250 for an entire course of treatment, from $10 to $20.¹

Although this price increase may look harmless, it caused a ripple effect felt by many patients, even those with insurance. Insurance companies started to restructure their formularies and placed the medication in a higher, more expensive tier so that patients were forced to pay higher co-pays for this medication.¹

Another example of pharmaceutical price inflation occurred in 2015 when Turing Pharmaceuticals increased the price of Daraprim (pyrimethamine) to $750 a pill, from $13.50 per pill.² Daraprim is commonly used to treat toxoplasmosis, a disease that may reside in as many as 1 in 5 Americans, yet poses little threat to healthy individuals. Patients who are immunodeficient, however, are at an increased risk for complications associated with this parasitic infection and are more likely to be hospitalized than those in the general population.²

More recently, criticism has been directed toward the makers of the lifesaving EpiPen auto-injector, Mylan, whose chief executive recently sat before a congressional committee to answer questions about the price increase of EpiPen auto-injectors to more than $600.³

Because of these and other occurrences of price inflation, patients are left on the outside looking in, wondering how they will afford their medications. One aspect of the Affordable Care Act has provided states with the means to expand Medicaid coverage to account for most adults that earn right around or less than 138% of the federal poverty line.⁴ Although this has addressed many patient care concerns, nearly 28 million Americans remain uninsured, and even with insurance, some patients are unable to afford their co-pays.⁴

Fortunately, there are numerous methods by which patients can obtain their medications at low cost, and pharmacists are perfectly positioned to help navigate this process.⁵

For many new, brand medications, manufacturers provide some form of assistance that can range from a 30-day free trial to a 12-month co-pay card that covers up to the full cost of the prescription, depending on insurance coverage, and up to a maximum annual benefit that is pre-specified by the manufacturer. How can pharmacists help their patients find these discount cards? One method is to simply search the manufacturer’s website for a patient assistance program or a co-pay savings card.

NeedyMeds is a helpful resource that can locate manufacturer co-pay cards, prescription assistance program (PAP) applications, and disease-based assistance programs.⁶ For manufacturer co-pay cards, patients may simply answer a few questions and fill in their personal information. Generally, many patients are eligible for a co-pay card, but exceptions may occur with those whose insurance is provided by a government agency (Medicare Part D, federal and state employees, etc.). PAP applications are typically for uninsured patients and require provider information and a signature accompanied by a prescription, as well as patient financial, income tax, and insurance information and signature. One caveat to keep in mind with these programs is that they may have maximum monthly and/or yearly limits on the benefits provided.

Both health care providers and patients can readily access information on patient assistance programs and applications for brand and generic medications. RxAssist is a website that contains a comprehensive directory of patient assistance programs that can be located through searching for a specific manufacturer or medication.⁷ Partnership for Prescription Assistance (PPARx.org) is a free service that helps identify public and private assistance programs for which a patient may be eligible, based on their medication list.⁸ RxHope is another service that patients and health care providers can access through the internet to search for available patient assistance programs.⁹ Furthermore, IndiCare is a website that allows for users to search for manufacturer-sponsored patient assistance programs.¹⁰

For insured patients, the Patient Access Network Foundation provides assistance based on the specific disease state, with a focus on those who have cancer or rare diseases such as Wilson Disease. However, it does offer assistance to patients with more common diseases such as asthma, heart failure, or rheumatoid arthritis. Financial assistance varies, depending on available funding, but this may be an ideal method for an insured patient.¹¹ For low-income Medicare Part D recipients, additional prescription support through a low-income subsidy (LIS) may be available. BenefitsCheckUp and Medicare.gov are online resources that provide applications for LIS and searchable databases with personalized reports detailing public, private, and state programs that offer assistance to patients with Medicare Part D.^12,13

Low-income uninsured patients may qualify for free or reduced-price medications through local health departments or state programs. For instance, North Carolina MedAssist provides free pharmacy services to residents of the states who are low income, uninsured, and fall at or below 200% of the federal poverty level. This program specifically targets residents with common diseases such as heart disease, diabetes, and asthma.¹⁴ The United Way’s 211 program provides numerous community resources for patients, including local medication assistance programs. Local United Way programs across the United States have even partnered with the discount savings program, FamilyWize, further expanding coverage for uninsured patients.¹⁵

Community pharmacies may offer a prescription savings plan or provide a list of generic medications valued within a discounted price range, based on the day supply.¹⁶ GoodRx coupons may provide a considerable discount and can be used to compare prices between pharmacies.¹⁷ Other strategies to address medication cost depend on patient factors and practice setting. Ideas include prescribing less expensive therapeutic alternatives, simplifying the regimen, keeping a clinic dispensary or samples, obtaining medications from charitable medication distributors, using over-the-counter medications, emphasizing nonpharmacologic approaches, and helping patients choose cost-effective insurance plans.

With so many strategies related to patient medication costs, why bother? For starters, financial incentives can improve adherence. This was shown in a randomized clinical trial, which incentivized patients to adhere to statin therapy. A caveat is that physicians were also incentivized for meeting LDL-C goals. Compared with the control group, adherence rates were higher in the patient-only incentive group (34% vs. 27%, P=.01) as well as the shared patient-physician incentives group (39% vs. 27%, P<.001), but not in the physician-only incentives group. Regarding clinical goals, these were only significantly improved in the shared patient-physician incentives group, in which LDL-C reductions were more profound (33.6, versus 25.1, P=.002), more patients reached LDL-C goals (49%, versus 36%, P=.003), and more patients received medication intensification (38%, versus 27%, P= .004), when compared with the control group. These differences were not seen in the patient-only and physician-only incentive groups.¹⁸ One key takeaway from this study is that though patient incentives did result in improved adherence, clinical goals were only met if providers were also incentivized. Also of note, patients were followed for up to 15 months, indicating the need for continuing adherence support. More studies exploring the impact of financial incentives on patient and provider behaviors will help us determine how best to focus our efforts.

As another example of the difference we can make by addressing medication cost, one hospital invested $5 million into giving free or reduced-cost medications to uninsured patients based on poverty level and, in return, saved $12 million by reducing emergency department visits and hospitalizations. This hospital used its 340B program to provide medications at discharge and subsequently refilled medications continuously. Thereafter, a portion of the hospital’s revenue was applied to a medication management program for this population, which helped patients better understand and stay on their medications, stay out of the hospital, and improve their health.¹⁹ This hospital’s valiant endeavor provides more answers for us to complement the aforementioned study. Removing medication cost barriers can set patients up for successful implementation of the individualized care plan diligently designed by the care team. Furthermore, these efforts should incorporate patient education and continuing support for medication persistence, as well as organizational buy-in and team member engagement for continued success. Overall, helping patients with medication costs has the potential to generate considerable financial and clinical rewards for patients and the health care system.

References

• Myrick S. Cost of doxycycline skyrockets. Vineyard Gazette. https://vineyardgazette.com/news/2015/09/24/cost-doxycycline-skyrockets. Published September 24, 2015. Accessed November 14, 2016.
• Lorenzetti L. Here’s why Turing Pharmaceuticals says 5,000% price bump is necessary. Fortune. http://fortune.com/2015/09/21/turing-pharmaceuticals-martin-shkreli-response/. Published September 21, 2015. Accessed November 14, 2016.
• The Henry J. Kaiser Family Foundation. Key facts about the uninsured population. http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population. Published September 12, 2016. Accessed November 7, 2016.
• Mangan D. Mylan’s EpiPen ‘greed is astounding ... sickening and disgusting,’ rep says. CNBC. http://www.cnbc.com/2016/09/21/mylan-ceo-says-epipen- profits-no-where-near-devices-600-sticker-price.html. Published September 21, 2016. Accessed November 14, 2016.
• Hester SA. PL detail&#8208;document, Guide for helping patients afford their medications. Pharmacist’s Letter. file:///C:/Users/cmollison/Downloads/310610.pdf 2015. Published June 2015. Accessed September 15, 2017.
• Find help with the cost of medicine. NeedyMeds. www.needymeds.com. Updated September 14, 2017. Accessed September 15, 2017.
• RxAssist: patient assistance programs center. www.rxassist.org. Accessed January 25, 2017.
• Partnership for Prescription Assistance. www.pparx.org. Accessed January 25, 2017.
• RxHope. www.rxhope.com. Accessed January 25, 2017.
• Patient Access Network Foundation. www.panfoundation.org. Accessed January 25, 2017.
• Indicare. www.indicare.com. Accessed January 25, 2017.
• BenefitsCheckUp. National Council on Aging. www.benefitscheckup.com. Accessed January 25, 2017.
• Medicare. www.medicare.gov. Accessed January 25, 2017.
• NC MedAssist. www.medassist.org. Accessed January 25, 2017.
• United Way of North Carolina. www.unitedwaync.org/nc211. Accessed January 25, 2017.
• Koval P, Yoder L, Hofmeier M, et al. Prescription discount plans. 2016. http://www.gahec.org/pharmupd/Discount%20Drug%20List%20December%202016.pdf. Accessed December 7, 2016.
• GoodRx. www.goodrx.com.
• Asch DA, Troxel AB, Stewart WF, et al. Effect of financial incentives to physicians, patients, or both on lipid levels: a randomized clinical trial. JAMA. 2015;314(18):1926-1935. doi: 10.1001/jama.2015.14850.
• Thompson B. Expanding patient care from 340B savings. Pharmacy Practice News. http://www.pharmacypracticenews.com/Policy/Article/11-16/ Expanding-Patient- Care-From-340B-Savings/38599/ses=ogst?enl=true. Published November 16, 2017. Accessed December 7, 2016.