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Clinical Updates — Clinical Updates

Patient Assistance Programs Provide Optimum Care for Patients, Treatment Options for Retina Specialists

Patients with AMD, diabetic macular edema (DME), retinal vein occlusion, and symptomatic vitreomacular adhesion are always hit hard by their diagnosis. The thought of possibly losing one’s vision is never easy to comprehend, but unfortunately, there are patients who decline treatments because they cannot afford them.

Many of us wouldn't think twice about paying a $100-per-month copay to preserve our vision, but the reality is there are many people with limited or fixed incomes who simply cannot afford even that amount.

Several programs are available to alleviate the financial worries on patients and provide retina specialists access to the treatment agents needed for optimum care. These patient assistance programs provide a range of benefits, from copay support to complete financial coverage. I estimate that 20% to 40% of my own patients benefit from these programs in one way or another.

The following is a summary of programs that have benefited my patients. A list of these and other programs, with phone numbers, is also provided. Because availability and eligibility for programs could change at any time, consult the program representatives directly for current information.
 

Chronic Disease Fund

Program overview:

• Provides copay/coinsurance for ranibizumab (Lucentis, Genentech, South San Francisco, CA), Eylea (Regeneron Pharmaceuticals, Tarrytown, NY), and dexamethasone (Ozurdex, Allergan, Inc, Irvine, CA) (RVO only)
• Based on household income of $50,000 per year, single; $64,000 per year, married

I have a DME patient who is on welfare. Following 2 bevacizumab (Avastin, Genentech, South San Francisco, CA) treatments, she informed me that this would be her last visit, because she could not afford even the Medicare rate for monthly treatments, due to her fixed income.

Through the Chronic Disease Fund, we were able to get her completely covered for the  treatments. When she learned that she would be able to continue her treatments, she came to tears.
 

Lucentis Access Solutions

Program overview:

• Coverage and reimbursement: benefits investigations, prior authorization assistance, billing and coding details, help with denials or appeals
• Patient assistance: referrals to the Genentech Access to Care Foundation (GATCF), Lucentis Copay Card Program, or copay assistance foundations
• Information resources: product distribution and replacement information, online
  patient management, educational programs, and communication services

GATCF

 
Program overview:

• Helps patients who lack insurance, lack coverage for Lucentis because a claim or appeal was denied, or lack coverage because the payer policy stages noncoverage
• Based on household income of $100,000 or less per year
• Patients must meet certain medical guidelines as set by GATCF

Lucentis Copay Card Program

 
Program overview:

• Provides copay/coinsurance assistance of 80% of patients’ out-of-pocket costs for Lucentis, up to $4000 in a 12-month period
• No income limit
• Works like supplemental insurance
• Other patient costs that might apply (ie,  copays for office visits or administration) are not covered
• Patients cannot be covered by any government plan (ie, Medicare, Medicare Advantage, Medicare Replacement, Medicaid, TRICARE, government employee plans)

Genentech also offers a sampling program for Lucentis, which allows retina specialists to trial Lucentis with specific patients, so patients can receive same-day treatment while determining insurance coverage. This also provides a time window to get the patient approved for a full patient assistance program, if necessary.
 

Eylea for You

Program overview:

• Free Eylea for on-label diagnoses only for uninsured patients
• Assistance to underinsured patients for out-of-pocket costs
• Based on household income of $100,000
• Patient must provide denied claim appeal, patient assistance appeal, and proof of income

This program also includes a copay program:

• Provides copay/coinsurance up to $370 per eye per month
• $4440 annual limit for patients with commercial insurance
• Based on household income of $100,000
• Patients must pay at least $5 out-of-pocket expense after insurance
• Patients cannot be covered by any government plan (ie, Medicare, Medicare Advantage, Medicare Replacement, Medicaid, TRICARE, government employee plans)

I have patients who have become refractory to Lucentis, so this program provides treatment options that otherwise may not be available.

As an example, I have an African American male patient with bilateral DME who had been on bevacizumab for 6 months. I switched the treatment to ranibizumab for 1 month and he did not show a response to it. Because he was approved for this program, I can now switch him to aflibercept and see if he responds differently to that agent.
 

Jetrea Care

Program overview:

• Based on household income of $100,000
• Provides Jetrea (ocriplasmin, ThromboGenics, Iselin, New Jersey) free of charge to uninsured patients
• Provides copay/coinsurance/deductible assistance in excess of $50
• Provides copay assistance to government-insured patients based on limited income

I have a 62-year-old female patient with a small macular hole with vitreomacular traction. Upon diagnosis, I informed her of her options, which were ocriplasmin or surgery, either of which would cost her around $4000.

Her insurance has a $5000 deductible and she did not have $4000 to pay for either option. She applied for this program and was covered for the entire $4000, which also went against her deductible. Not only was she able to begin treatments, the decrease in her deductible balance also makes the option for surgery far more affordable, should it be necessary.
 

Additional patient assistance programs

Two other programs that are available to patients:

• Allergan OZURDEX Patient Assistance – uninsured and underinsured patients

• Valeant Ophthalmics Visudine Focus on Access – uninsured patients or patients whose insurance does not cover Visudine

Contact these programs directly for eligibility and financial assistance details.
 

Enrolling patients

In my practice, I have a central point of contact to help navigate patients through the approval processes for these programs. Having a person who is knowledge about the programs typically results in patients being approved quickly, thus providing faster access to the agents I need to begin or continue treatment.

If you have a very busy practice or lack the human resources to designate someone to manage these programs, patients can apply on their own. Each program provides online information and enrollment, as well as toll-free phone numbers to speak with program representatives to get complete information and eligibility requirements and status updates on applications.
 

Benefits to patients and retina specialists

A reality of ensuring proper treatment for patients with chronic diseases is the ability—for some of them—to afford the medicines needed for their treatment protocol. This can range from underinsured and noninsured patients to those who may have coverage but due to financial hardships cannot afford the deductible or copay required for the agents. With patient assistance programs such as these, patients don’t have to endure the stress of how to afford treatments, or worse, decline treatment altogether.

Retina specialists also benefit because we have access to the necessary agents to begin treating our patients, as well as the flexibility to change medications as needed based on the patients’ responses. We are extremely fortunate to have amazing therapies to treat the most common conditions we encounter, but breakthrough therapies can also come at a substantial price to patients, thus limiting our access to them. It is an additional reassurance that these programs can provide us access to these treatments.

Posted July 5, 2013