High Cost Meds and ACA

[kgmom219]

Any ideas on where I can find the list of drugs or dollar threshold or SOMETHING that can tell me what's part of this. All I know is that expensive drugs have a rebate/coupon/discount and the drug companies have to administer it.

Thanks!

 

[Post Quartermaster]

You're gonna have to be a little more specific here.....

 

[kgmom219]

Rumor has it that part of ACA is that the drug companies are required to help with the EXTRA expensive medication. I've heard it mentioned a couple of times from clients (and really wondered what they were smoking), but today I heard about it from a Chemo pharmacy. My client is on chemo and the pharmacy told her to call Merck (who makes her chemo) because they are supposed to pay for some of it, due to ACA. Client called Merck, who said "yes, you qualify and it takes 3 days to process". Client is not on the exchange.

So...that's what I've got. Any thoughts?

 

[FLM2]

Rumor has it that part of ACA is that the drug companies are required to help with the EXTRA expensive medication. I've heard it mentioned a couple of times from clients (and really wondered what they were smoking), but today I heard about it from a Chemo pharmacy. My client is on chemo and the pharmacy told her to call Merck (who makes her chemo) because they are supposed to pay for some of it, due to ACA. Client called Merck, who said "yes, you qualify and it takes 3 days to process". Client is not on the exchange.

So...that's what I've got. Any thoughts?

I don't know that there is a list but have clients on Off Exchange plans that take Humira, which is about $2500 a dose-they get help that results in a $5 copay for the 1st dose and a $1995 subsidy. After the the Patience Assistance plan pays $2K per dose if insurance doesn't cover it.

I put those clients on plans with $2K deductible and 100% after that so they will only have $5 OOP for all their medical care for the year.

Hard to believe but true.

 

[Post Quartermaster]

Rumor has it that part of ACA is that the drug companies are required to help with the EXTRA expensive medication. I've heard it mentioned a couple of times from clients (and really wondered what they were smoking), but today I heard about it from a Chemo pharmacy. My client is on chemo and the pharmacy told her to call Merck (who makes her chemo) because they are supposed to pay for some of it, due to ACA. Client called Merck, who said "yes, you qualify and it takes 3 days to process". Client is not on the exchange.

So...that's what I've got. Any thoughts?

Sounds like a Pharmacy Assistance Program (PAP). They have been around long before the ACA. As far as I am aware, PAP's exist solely out of "good will" from manufacturers. Humira, Enbrel, and many others have PAP's available....


...of course, you may substitute "good will" for "profit motive"....

 

[AllenChicago]

I'm learning something totally new here. Are these Pharmacy Assistance Programs income/needs based? Thanks KGMom for bringing this useful info to the forum!

 

[somarco]

Home Page - NeedyMeds

Prescription Assistance Program |

RxAssist - Patient Assistance Programs

just to mention a few.

Each program has their own rules. Manufacturers look at income, assets, current coverage. . . .

The pharma companies get tax breaks in exchange for providing assistance. As PQ said, this is not new. Been around for years.

 

[AllenChicago]

I've sold mostly 100% Rx (after the deductible) plans since 2003. Have never needed to look at PAPrograms for any clients. Now, thanks to big holes in ObamaScare plans, it would be wise to learn more about this safety net. Thanks for the various links Somarco.
-allen

 

[somarco]

100% is great as long as the med is on the formulary. Finding that information can be a real challenge.

 

[kgmom219]

I'm not talking about the previous programs. Those I knew about.

The pharmacist at UT Southwestern (that's the big cancer center in Dallas) told me that a lot of the chemo drugs are now being covered by the various drug companies, because that was part of "Obamacare".

Since I have to call the pharmacy in the morning, I think I will get the number she gives out. My client called Merck today and I am guessing there are other manufacturers participating.

Best place to get a formulary will be the prescription benefit manager.

And just so you know, I was told today that the systems were not set up to give each other the deductible information. I get that its 2 different systems. I get that its not real time. But they should be able to do it when required. Like this woman, who has met $3K in medical already and her chemo is $1K/day. I can't get the system updated so she doesn't have to pay past Wednesday. NOT HAPPY