How to manage the system and be able to afford coverage for the prescriptions you need.
When Jacqueline Herships went to her local pharmacy to pick up her one-week supply of ATRA, an oral vitamin-A-based compound used to treat leukemia, she experienced sticker shock. The $5,000 price for her prescription was more than she — or most — could pay.
Herships, who works as a public relations specialist, felt overwhelmed. She knew she needed the drugs to fight her cancer. She also knew that paying $5,000 every week was not going to happen.
Self employed and living in South Orange, N.J., Herships reached out to Edgar Brisbon, who describes himself as a mercenary for seniors. Brisbon, a certified senior advisor, runs Silver Lining Advantage, where he consults and helps people navigate the rough terrains of health insurance and healthcare administration.
Brisbon was able to knock the $5,000 price down to $9. That’s because Brisbon looked at her finances and saw that Herships qualified for the Pharmaceutical Assistance to the Aged and Disabled (PAAD) program in her state. The program assists low-income individuals residing in New Jersey with the costs of their prescription coverage.
According to Brisbon, many states have similar programs that help people in specific income brackets cover the costs of targeted medicines. He suggests starting with the Patient Advocate Foundation, a national 501 (c)(3) non-profit organization that provides assistance with health insurance, job retention, and debt crisis matters related to your specific diagnosis of life threatening or debilitating diseases.
Herships recommends hiring a patient advocate. Trying to pay for prescription medicines that keep you well and fight disease can be overwhelming for most. “Some days the drugs make me feel exhausted or ill,” she said. “Having someone who can focus clearly when I cannot, due to the meds or being on chemo, is a huge help. A patient advocate works on your behalf, and in my case has identified ways to make treatments affordable.”
Her treatment was tailor-made for her by her doctors. This approach is called precision or personalized medicine. Personalized medicine uses information about an individual’s genes, proteins, and environment to prevent, diagnose, and treat disease. Most people with the same diagnosis receive similar treatments. With precision medicine, according to the National Cancer Institute, treatments will one day be tailored to the changes in each person’s cancer.
One study found that targeted cancer therapies work. However, personalized treatments come with a high cost. “Because of how insurance works, we found huge differences in costs based solely on whether chemotherapy is swallowed as a pill or infused into a vein,” Fabrice Smieliauskas, PhD, assistant professor in the Department of Public Health Sciences at the University of Chicago, and co-author of the study, said. “With so many new drugs available, patients and oncologists have the benefit and the burden of choice, and should be prepared to discuss how costs might figure into their preferred treatment approach.”
The study also pointed out that “targeted therapies and price inflation at all stages of the drug lifecycle highlights the need for creative use of value-based managed care by private payers to curb escalating costs of anticancer drugs.”
While paying for targeted medicines is tricky, like in Herships’ case, it can be done. Brisbon mentioned that you should talk to your doctor, your health insurer, and even the drug manufacturer. The drug manufacturer may have a separate foundation to pay for your medications. “For instance, AstraZeneca, a pharmaceutical company, as well as other companies, offer patients free or partially-covered medications,” Brisbon said. “You can talk to your doctor, pharmacist, patient advocate, or go online to see if coverage is available.”
Another option is if there’s a clinical trial that you can join, the cost may be covered by the organization sponsoring the trial or by your health insurer.
Brisbon also found that many consumers don’t always embrace using generics. “Taking generics over brand names will save you a lot of money,” he said.
March 31, 2020
Christopher Nystuen, MD, MBA