Patient Advocacy: Healthcare on your side
by Martine G. Brousse,
Healthcare Specialist, Patient Advocate, Certified Mediator
Paying for Prescription Drugs
Part I: Infused or Injected *
Infused or injected treatments are common, ranging from a 32-cent B12 injection to thousand-of-dollars chemotherapy infusions. Due to medical and liability reasons, these are mostly given in office or facility settings, and are billed to Medicare under part A(inpatient) or B (outpatient or office), and to commercial insurances under the Medical benefits portion of the policy.
Many such treatments use brand-name drugs, often associated with prohibitive costs. These medications are not covered or payable under the Pharmacy benefits of your policy when administered in hospital or office settings.
There are options to lower your costs. Here are some tips:
1. Visit the Manufacturer's website
Almost all manufacturers offer so-pay assistance programs to self-pay patients, or those with a high share of cost. While income maximums may be in place, they are not mandatory. Grants can be generous ($ 24,000/yr for Herceptin from Genentech for example), but will not cover off-label (not FDA approved) use. Ask the office for an application form.
Self-pay or cash patients might qualify for free drug donations, based on criteria specific to each product.
Medicare, Medicaid or Tricare patients are prohibited by law from applying directly for funds, but may qualify for indirect assistance (see below)
2. Public & private Organizations
Every disease or condition has likely created an organization dedicated to its education and support. Cancer patients, for example, have access to various general federal agencies, as well as numerous private societies.There, should be listed general and focused charities, offering financial assistance and free resources. Healthwell or Copays.org are such well-known programs.
Please note that private funds often run out of funds early each month; applying the first week is best. Grants are not retroactive so requests should be made before a treatment starts.
3. Do it at home
Some infusion treatments, including those less complicated such as IV iron, IVIG, zoledronic acid for osteoporosis (Zometa, Reclast), etc, can be safely administered at home by a visiting nurse. Although the first regimen will be given in the office or facility to rule out any allergic reaction, subsequent home treatments may be cheaper.
Take too into consideration these hidden costs: time taken off work to go to the office, parking fees, the risk of infection in crowded waiting rooms, or the discomfort of leaving home when not feeling well (especially after a chemo treatment).
Injections such as growth factors for anemia (Procrit, Aranesp) or for neutropenia (Neupogen) for example, can safely be self-administered (syringes come pre-filled and require no medical background). Others like B12 injections can be administered at home via a home health agency. In these cases, your pharmacy benefits, or Part D will be responsible for the authorization, delivery and payment of the drug.
Calling your insurance carrier to compare costs, verify coverage and work the set-up is a must. As this option creates more paperwork for your doctor, and extends his legal liability beyond his active control, he is likely to be more supportive if most details, such as locating an in network home health provider, have already been worked out.
4. Use specialized mail order pharmacies.
If you are self-injecting at home without the help of a health agency, your prescriptions will be filled at your local or mail order pharmacy. Try contacting TNH or US Bioservices in such cases. They may not be contracted with your insurance, but their staff is trained to locate and apply for financial assistance on behalf of patients. This service can save you $ and efforts.
5. Question your physician
Convenience and habit may lead to prescribing costly regimens and medications when cheaper or generic alternatives are equivalent. Less expensive treatment options are often available, with the added advantage of having proven their value and effectiveness.
An active dialogue with your physician, especially when explaining your financial situation, can benefit both sides. After all, the office has an incentive to help you in order to get paid promptly in return.
There may be more help out there for you than you may realize. I specialize in oncology, and know that for a fact for cancer patients. Asking the office staff is the first step, doing basic internet research is next. For those who are not computer-savvy, your local library, church or teenage neighbor may be helpful.
* as seen on NerdWallet
* as seen on NerdWallet
Next week: Part II: Oral Prescriptions
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©  Martine G. Brousse.
All rights reserved.
My objective is to offer you, the patient, concrete and beneficial information, useful tips, proven and efficient tools as well as trustworthy supportive advice as you deal with a system in the midst of sweeping adjustments, widespread misunderstandings and complex requirements.
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