Patient Advocacy. Access, Affordability, and understanding treatment costs.

Presented by: Dean Gruber, RPh, Pharmacy Manager at Community, A Walgreens Pharmacy David Straseski MSSW, LCSW, OSW-C, Lead Oncology Social Worker at Aurora Cancer Care Lauren Marquardt, UW Pharmacy Student-Class of

3 Insurance Types State Funded Insurance – Wisconsin ForwardHealth BadgerCare Plus – Health care for children, pregnant women, and adults » Adult with income at or less than 100% FPL » Eligible patients above 100% FPL are asked to use the healthcare exchange, Medicare D, Senior Care or other programs » Eligibility exceptions can occur

2014 Poverty Guidelines 4 Topics/Eligibility/Downloads/2014-Federal-Poverty-level-charts.pdf Family Size100 % FPL 111, , , , , , , ,090.00

Insurance Types State Funded Insurance – Wisconsin ForwardHealth Medicaid for Elderly, Blind or Disabled – Eligibility: » Age 65 or older, blind, disability » Family income and assets are at or below monthly program limit » United States citizen or qualifying immigrant 5

Insurance Types State Funded Insurance – Wisconsin ForwardHealth SeniorCare Prescription Drug Assistance – Wisconsin residents who are 65 or older » Must pay $30 annual enrollment fee per person » Only income is counted. Assets such as bank accounts, insurance policies, home property are not counted » Four levels of enrollment based on income » Subject to certain annual out-of-pocket expense requirements depending on annual income. » Drug coverage varies by level of enrollment 6

Insurance Types State Funded Insurance – Wisconsin ForwardHealth SeniorCare Prescription Drug Assistance – Wisconsin residents who are 65 or older » Can be stand-alone credible coverage for patients who would be required to pay a fee for late enrollment into Medicare Part D. » Can also be a supplement to Medicare Part D coverage. 7

Insurance Types – Wisconsin ForwardHealth SeniorCare Prescription Drug Assistance – Four levels based on income limits: – NOTE there is no asset limit 1. At or below $18,672 per individual or $25,168 per couple annually. 2a. At $18,673 - $23,340 per individual and $25,169 - $31,460 per couple annually. 2b. At $23,341 - $28,008 per individual and $31,461 - $37,752 per couple annually. 3. At $28,009 or higher per individual and $37,753 or higher per couple annually. 8

Insurance Types Affordable Care Act (Non-Medicare) – Pick the insurance that fits your needs from the Marketplace – Metal Tiers Tiers are assigned an “actuarial value” – Refers to the healthcare expensed the plan will cover – The higher the actuarial value, the lower the out-of-pocket cost 9

Insurance Types Bronze plans will have lower premiums, but higher out-of-pocket costs (60% coverage) Platinum plans will have higher premiums, but lower out-of pocket costs (90% coverage) – Bronze Plan – Silver Plan – Gold Plan – Platinum Plan 10

Premium Subsidies Available Premium cost subsidies will be available to people with incomes from 100% of the Federal Poverty Level to 400% of the Federal Poverty Level (FPL). Applies to silver plans only. Examples of 400% of FPL in Wisconsin: 1 member in family$ 45,960 2 members$ 62,040 3 members$ 78,120 4 members$ 94,200 5 members$110,280 6 members$126, members$142,440 8 members$158,520 11

Insurance Types Commercial Insurance – Plan coverage varies widely in benefit design based on the type of plan 12

Insurance Types Federally Funded Insurance – Medicare Federal healthcare coverage for people 65 or older, or those under 65 found disabled by Social Security Administration. 13

Insurance Types Federally Funded Insurance – Medicare A Covers: – Inpatient hospitalizations – Skilled Nursing Facility – Inpatient psychiatric care – Hospice Premium free if have enough Social Security work quarters 14

Insurance Types Federally Funded Insurance – Medicare B Covers: – Doctor visits – Outpatient services » Infusion administration » Medication coverage for VELCADE® – Certain oral oncology medication » oral Cytoxan® (cyclophosphamide) – Services Part A does not cover Late enrollment penalty if you do not sign up when first eligible. Monthly premium: $

Insurance Types Privately run under Federal guidelines – Medicare supplement insurance (Medigap) Sold by private insurance Help pay health care costs that are not covered by original Medicare – Deductibles, co-insurance, and co-payments Medigap does not work with Medicare Advantage Plan 16

Insurance Types Federally Funded Insurance – Medicare C (Medicare Advantage Plan) Covers: – Offered by private companies approved by Medicare – Get Medicare A and B coverage from your Medicare Advantage Plan – Most Medicare Advantage Plans offer Part D prescription coverage » Can vary depending on the type of plan – Coverage is variable and dependent on the plan 17

Insurance Types Privately run under Federal guidelines – Medicare D Covers: – Prescription Drug Coverage Premium varies depending on plan Co-pays vary per drug, plan, and pharmacy 18

Insurance Types Federally Funded Insurance How does Medicare Part D work? – Broken down into four parts 1.Part 1: Initial $310 deductible 2.Part 2: Coverage -75% covered by Medicare, up to 25% covered by individual -Enter Doughnut Hole at drug costs of $ Part 3: The Coverage Gap “The Doughnut Hole” -Medicare Part D plan will pay 28% of your generic medication costs and the Brand-name drug manufacturer will pay 52.5% of your brand-name drug expenses 4.Part 4: Catastrophic Coverage - Co-payment of 5% 19

Co-Pay Cards Co-pay cards are available for many branded products for treatment and side effects – Cannot be used for patients with Medicaid or Medicare – Can be used in addition to commercial and most ACA plans 20

Co-Pay Assistance Foundations All insurances eligible, including Medicare Part D and SeniorCare Dependent upon income level, household size, diagnosis and medication Funding based upon a grant through an organizations, exact details are based upon each individual organization and patient specific factors 21

Manufacturer Coverage Some individuals may be eligible for direct coverage through the manufacturer based on financial needs 22

Co-Pay Assistance Foundations Four of the main organizations that have funding for multiple myeloma 1.Leukemia and Lymphoma Society – 2.Patient Access Network Foundation – 3.Chronic Disease Fund – 4.Patient Advocate Foundation – 23

Typical Case: Myeloma patient on an oral therapy Average age of onset is 70 years of age – Most patients will have Medicare Part D coverage Medicare Part D – Deductible: $310 – Coverage: 75% covered by Medicare up to $2850 – Donut Hole: Medicare covers 28% for generic and manufacturer covers 52.5% for brand, rest is paid by patient – Catastrophic: 95% coverage 24

Typical Case Scenario – Revlimid® Cost: $9,000 - $12,000 per cycle 25 Deductible $262 Coverage $635 Coverage $635 Donut Hole $1759 Catastrophic $ 143 Patient has not met $310 deductible $2850-$310 = $2540 $2540 (25%)= $635 $3704(47.5%) = $1759$2877 (5%) = $143 Total patient cost without copay assistance = $2,799 Copay assistance grant will cover total cost of $2,799

Typical Case Scenario Patient has made it to catastrophic coverage with one Revlimid® fill For additional refills the patient will pay 5% of prescription costs in catastrophic (approximately $ per refill) Coverage for first fill and refills are typically not exceeded by the yearly grant amount – Leukemia and Lymphoma Society Grant $10,000 grant – Patient Access Network Foundation $10,000 grant 26

References Forward Health- The Connection to Health Care Coverage and Nutrition Benefits. (July 2014). Retrieved August 15, 2014 from Poverty Guidelines. (2014). Retrieved August 15, 2014 from Topics/Eligibility/Downloads/2014-Federal-Poverty-level-charts.pdf How Part D Works? (July 2014). Retrieved August 16, 2014 from The Official U.S. Government Site for Medicare. (2014). Retrieved August 16, 2014 from Affordable Care Act. (2014). Retrieved August 16, 2014 from 27

Questions? 28

00/00/2013 thank you