ADVOCACY FOR COMPLEX DRUG CLAIMS: Raymond Rupert MD. MBA. Rupert Case Management Inc.

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TAKING PATIENT ASSISTANCE PROGRAMS TO THE NEXT LEVEL:

Raymond Rupert MD. MBA.
Rupert Case Management Inc.

800 620 7551

INTRODUCTION TO BIOLOGICS:

Biologics change everything. Smart medications that target the source of the disease are the foundation for personalized medicine. The treatment outcomes can be outstanding. Unfortunately, these medications are expensive and this has lead to challenges with drug claims and reimbursement.

COMPLEX DRUG CLAIMS:

Drug claims for biologics can be complex. Biologics are new and expensive drugs. In some cases, they are used for many years. Drug insurance plans vary in design. Some insurance plans use stop loss with limits well below the average cost of biologics. Other insurance plans provide catastrophic coverage but these plans are also providing challenges for patients.

PROVINCIAL AND PRIVATE DRUG PLANS:

Some biologics are covered by provincial plans. Other drugs are covered by private insurance plans. The provincial plans lag the private plans by up to one year or more. Furthermore, there are rules about where the infusion of privately funded or publicly funded drugs can take place. To be successful, patients must anticipate and comply with these rules. The infusion site has to be indicated on the application for the biologic. It is helpful for the advocate to have established relationships with infusion clinics and supervising doctors in various communities.

PRIOR AUTHORIZATION:

The prior authorization process established by the PBMs is not transparent. It should follow the evidence and published clinical guidelines. However, there is a strong emphasis on substitution of medications that are older, less expensive and possibly less effective. This follows the example of the successful cost savings of generic drug substitution. However, there are no generic versions of biologics that are widely available.

CATASTROPHIC DRUG INSURANCE:

Catastrophic drug insurance should fund the cost for biologics for a multi-year program of treatment. That was the logic of the design of the insurance product.

Unfortunately, some insurers are informing patients that “8 months is enough”. Effective drug claim advocacy is required to reinstate treatment.

THE PATIENT JOURNEY- THE PATIENT EXPERIENCE:

The patient experience can be very frustrating. There are barriers to access through out the journey including at the time of submission of a request for a biologic. The “prior authorization” process is a significant barrier. To overcome this barrier,advocacy can be very important. The advocate must have a detailed understanding of the disease, the role of substitute drugs, the chronology of the patient’s prior treatments, the published evidence and clinical guidelines, the relevance of employing the biologic and cost/benefit ratio for the use of the biologic.

PATIENT ADVOCACY GROUPS ( PAGs):

Patient advocacy groups are playing a larger role in educating their members and the public about biologics. PAGs target the biologics that relate to their member’s disease. Some PAGs have activist agendas using social media to advocate for their members.

ADVOCATING FOR PATIENTS:

It is our experience that an effective, informed, technically competent and persistent advocate is required in order to be successful in receiving approval with a complex drug claim.

Copyright:  Rupert Case Management Inc.

www.rupertcasemanagement.com