Drug Coverage 101 | Presented by Yvonne Ta
Hello every one and welcome to today’s Lunch and Learn. My name is Michelle Snow and I am Patient Education Librarian here at Princess Margaret Cancer Centre and I will be introducing our speaker today. The topic is on drug coverage and our speaker is Yvonne Ta. Yvonne Ta is a medical reimbursement specialist here at Princess Margaret Cancer Centre. Yvonne graduated from U of T with a bachelor of science and she started working at Princess Margaret Hospital Outpatient Pharmacy in 2000, then she moved to the Clinical Trials Pharmacy in 2005 and she has been the medical reimbursement specialist since 2010.
Yvonne has an in-depth familiarity with both Provincial and Federal drug reimbursement programs and patient assisted programs. She can help relieve the burden of financial anxiety from our patients by helping them apply for and receive drug coverage. So please join me in welcoming Yvonne Ta.
Thank you Michelle and thank you for inviting me for this talk. Today we’re going to cover drug coverage. It’s going to be very basic about Drug Coverage 101. The discussion topics today are going to be the introductions of oncology medications and costs and the medication reimbursement role which is abbreviated by MRS, which is very lengthy.
Also, medication coverage works in Ontario as well as how to contact an MRS, then questions and answers at the very end and closing. With all my presentations I love to present the slides even though it’s a bit dated. It’s a Canadian Cancer Society cancer drug access for Canadians report back in 2009 despite it is some years ago, if anything the numbers will be higher at this point so about 50% of newer cancer drugs are taken at home, as a result the patient needs to pay for the cost of the medication. So anything taken at home will be the patients’ responsibility to pay.
About 3/4 of the drugs taken at home cost about $20 000 per year. Unfortunately this is definitely an underestimate at this point and the average cost of a single course of treatment for more recent drugs costs about $65 000 per year and that is almost as high as the average annual income of Canadians. Michelle mentioned this role started back in 2010 and it started as a proof to concepts project. At that time our outpatient pharmacy manager saw the need for getting treatments for cancer medication or coverage for cancer medications. That’s where this role came up at the time. So it started with one person and now we’ve grow to a team of five.
So the role for the medication reimbursement specialist, if you want to take a look at the circle of care, patients get seen by doctors and then the nurses as well, social workers and a pharmacist and then we get involved in getting treatment in place and finding financial assistance. And it depends on the sites, depends on the doctors as well as the nurses, sometimes we get referrals immediately when doctors are seen we get a call from the clinic and then we see the patient immediately. Sometimes we may not see the patient until they are at the outpatient pharmacy and then realizing that the costs of medication is not affordable or the drug is not covered by their plan. A lot of times when the patient tells physicians that I have private insurance it doesn’t end there. So it really means we have to go in depth into that question. Private insurance doesn’t mean everything is covered, when you have OHIP it doesn’t mean that everything is covered as well. So the role of the Medication Reimbursement Specialist, so that way you just have a clue as to what we do, we mainly focus on facilitating drug access for oral and take home medications only and we assist patients with their insurance navigation and appeals whether is through the insurance company itself or through the employer.
Depending on the comfort level of the patient because some patients do not want their health condition to be disclosed to their employer, so it really depends on their level of comfort and this transparency. And so we assist patients with their Trillium Drug Coverage application and expediting approvals for urgent cases. If patients were to fill out the application and it’s filled out correctly, it would probably take at this time, which is outsourced by the Ministry of Health, it will probably take about four to six weeks. If they are behind it could take anywhere up to three months. If there is misinformation it could take longer. If the application is deemed urgent, we could have it expedited within usually twenty four hours to three to five business days I should say. We also assist physicians with exceptional access program submission which is known as EAP and some follow ups as well. We also assist clinicians with private insurance authorization forms and also follow up as well.
That process I’ll go into details later. And so also the most important thing is…the uniqueness of the Medical Reimbursement Specialist at the Princess Margaret Cancer Centre, it’s because we focus on coverage optimization, that’s very, very important. What we do its coordination of benefits with private and private or private and provincial and we also enrol patients for patient assistance program for either co-pay deductible assist where applicable bridging compassion supply. And most importantly we don’t look at each case as individual; we look at each case as a whole. So the patient has a maximum for the family, we also consider as a whole what other medications is your family on if they are covered under this plan so we don’t want to exhaust the insurance for one patient and then leave the rest of the family members in the hole so we also look at that and we also look at not just the oncology medication but other maintenance medication. If we exhaust the insurance over oncology medications what’s going to happen to the maintenance medication so we take that as a whole, we look at it as a whole picture. We also find coverage for unfunded drugs and that’s done either through the appeals through the exceptional access program which we do very frequently and the case by case review program through the Cancer Care Ontario.
So the case by case Review program is the only oral agents that Cancer Care Ontario takes care of. CCO, they mainly house IV medication and we appeal to private insurance via employee escalations as I mentioned before. Again it really depends on the comfort level of the patient and how big the employee size is.
A small company, how does it affect the premium of the whole company, if it’s a big employee, it’s a bit more saturated then the impact is not as big so we have to take this case and look at it as a whole. Currently I have a case right now and it’s a small company however to get that medication covered, it wasn’t covered and through appeals it wasn’t covered but because it was an open access plan I can work with the employer and get it covered but with that being covered it would increase the premium for the whole company. The company is less than thirty people so once the premium goes up as we all know with the insurance company we all know it’s not going to go down the following year.
It’s going to stay at that level so we have to put that into consideration as well. And if all fails we go pharma and we ask for compassionate medication s. It depends on pharma, it depends on the clinical situation, it depends on the patient’s financial situation. And so our role here is to exhaust all avenues of coverage. So what coverage is available to me if this is the pharma patient’s perspective via private coverage or provincial coverage? Private insurance-- can be employee sponsored or self-purchased. So for an employee sponsored plan if we are, let’s say we all have Sun life plan but my coverage and your coverage may differ depending on what plan we choose so we tell patients all the time and prescriber all the time, that coverage varies from individual to individual, insurance to insurance so we don’t have a generalized answer. If a patient comes to me and says I have a Sunlife plan can you tell me my coverage? It really depends, like I mentioned we can both have the same plan but the coverage may be very different and if it’s a self-purchased plan usually they are self-employed or they have a small company.
The plans are very limited and access to private insurance does not always mean adequate drug coverage. That’s very very important. So that’s where the stumble block is. Usually when the physician asks do you have private insurance? Yes I do and it ends there. And then they would prescribe. It actually goes beyond there. The questions that we need to know is with majority of oncology medications prescribed now, I can safely tell you 99% of medications for insurance will require what’s called special authorization except for if you are a federal employee which is a PSHC plan, that’s a plan that will cover everything and anything for now until further changes. So we have to make sure there is a special authorization required, if there is… does the patient meet criteria, is this insurance and open access plan, is it a formulary based plan.
So those are the things we look into. The percentage of coverage, is it 80% is it 90% is it 100. I mean I’ve seen as low as a 20% plan where the plan pays 20 and the patient pays 80 and that’s quite common now, I’ve seen about two or three already so far and an annual lifetime maximum so that’s very very important. We’re talking about medication that costs $10 000 per month, to go to the extreme.
That’s $120 000 per year if the insurance has a $10 000 max its pretty much considered useless at this point. Even with insurance some patients may forgo treatment because they cannot afford the out of pocket expense. So just make sure it doesn’t end at.. “I have a private insurance”… it goes beyond that.
Provincial coverage is known as Ontario Drug Benefit in Ontario so it’s abbreviated by ODB. So you hear a lot about that in relation to ODB. So just make sure it’s not the same as OHIP. Doesn’t mean that I have OHIP I have ODB coverage.
But you need OHIP in order to obtain ODB coverage. ODB coverage provides coverage for oral or take home medications so no IVs with the ODB coverage and so coverage is subject to the list on Ontario Drug Benefit formulary which is a provincial Ontario Drug benefit formulary. So again even if you have ODB not everything is covered. Many cancer medications potentially funded will require what’s called exceptional access program which is formally known as section 8, section 16, ICR and now it’s called EAP. So if someone is using the term section 8, its takes their time.
Approvals are limited and to disease specific criteria so you have to meet the criteria as well as when its approved its approved for a duration period, it’s not ongoing. We can always reapply again as long as patient shows a positive response. Response takes about 2 to 3 weeks depends on the medication, depends on how busy the EAP ministry of health office is and sometimes it could take months.
So it really depends on the medication, depends on how urgent it is, but if we know the case is urgent we’ll get a response quite promptly. So I just want to show because like a lot of the time I get patients coming to me, I am over 65 but the drug is not covered by Trillium. That’s a very very typical case that we have all the time so I just want to give you a visual of what ODB is. So think of it as an umbrella. So ODB is at the very very top, its Ontario Drug Benefit and on the bottom of the umbrella these all belong in ODB so if you are a senior, 65 and over, you will be automatically be enrolled into the seniors plan. So let’s say I turn 65 today February 23rd.
My coverage actually won’t kick in until March 1st. So it’s always the following month of the first day. So my coverage actually don’t kick in of March the 1st.
Or sometimes if the patient needs treatment within this period of time we might have to apply for Trillium to tide them over. There is no other insurance and if a patient is receiving ODSP which is Ontario Disability. So sometimes a patient might tell you “I’m on disability”, the key question is are you on Ontario disability or Canada disability? If you are on Ontario disability, you get a monthly drug card but if you are on Canadian disability you don’t get any drug card at all and Ontario Works which is formally known as welfare. So that’s Ontario Works. If patients are receiving home care service, sometimes, not all the time, depends on the lengths and depends on the budget availability, we may be able to access a home care drug card. So we always tell a patient that’s a bandage solution because when your homecare ends, your coverage ends. On the homecare drug card it has an estimated end date.
With the estimated end date it could be later or it could be before.. Again it depends on the service end. We don’t like to use that as a permanent solution. It could be a bandage solution to get them onto medication and then to apply for the permanent solution which is Trillium Drug Program if they have insufficient private insurance or no private insurance. So just remember again the take home message is that ODB falls under this entire umbrella so if you’re already a senior there’s no point in applying for Trillium because the coverage is exactly the same and it’s just the deductible that’s different.
This varies from program to program. And there’s one that’s long-term care which we don’t have any of our patients here. This is a drug card that’s presented for long-term care patients who are residing in long-term care home but they have designated pharmacy that fills for them. And just a bit in depth about ODB, so just to mention to you so patients who are 65 and over will have ODB they don’t need to apply.
It will automatically be applied to them comes the following month of the first day. If you consider low income seniors which is $16 000 per individual or $24 000 per household which is what you need to apply to have the $100 dollars waived so the deductible for a senior is $100 every year August the 1st. So if they are considered low income, it doesn’t automatically place them in the low income bracket they have to put in the paperwork and apply and put in their notice of assessment to prove their income. Everyone is considered high income, let’s put it this way, unless you deem yourself low income with a notice of assessment. And a patient on social assistance which is Ontario Works gets a monthly drug card and they have to present the monthly drug card every month to the pharmacy to fill their medications. Patients receiving home care services, as we mentioned, and patients who reside in long-term care homes and patients on the Trillium Drug Plan.
With the senior plan $ 100 every year and then so with the deductible its either $4.11 or $2 when they fill it out with outside pharmacy and with the hospital it’s a bit different. It’s either $2 or no charge and with social assistance there’s no charge or $2. The majority of pharmacies will waive that $2 anyways, at least the pharmacy downstairs does. Patients receiving homecare is the same thing, its $2 or its waived depending on the pharmacy. Trillium is a bit different so let’s go into that one.
So with trillium drug programs with patients with no private insurance or insufficient private insurance and has high out of pocket prescription costs. We get a lot of these questions or these statements coming from prescribers, or nurses or patients saying that “OH I don’t qualify for Trillium; I make too much money to qualify” … so that’s never the case. As long as you are an Ontario resident, you have a valid OHIP card that is active and if you are able to provide proof of income for the previous tax year. If you haven’t filed taxes there is other ways.
For wxapmle, a T4 would also be sufficient or you could get a lawyer or accountant to prove your income. That would be sufficient as well. So these are the three criteria that you need to qualify for Trillium. So if your patient tells you that I don’t qualify for trillium just ask these 3 questions. Do you have these 3, if you do then you qualify, the only difference that would make my application different from your application is our income so there is a deductible which is estimated approximately 3-4% of combined household net income, so when you apply for Trillium it’s a household net income. So if I were to apply to trillium for myself I would have to include my husband, the spouse is always deemed dependant unless you’re not married.
And my children would be deemed dependant so they would have to be included on my application. Unless my children are deemed financially independent and are over 18 then I can exclude them from my application. It’s always a house hold application. So bear in mind trillium drug plan is a bit different, the policy here doesn’t run calendar year. It starts August the 1st of every year so the trillium for this year started August 1st 2015 and its going to end July 30th 2016. So usually at the end of the July 31 comes the August 1st if a patient has not renewed the Trillium that’s when the pharmacy would find out because when they put through the medication it’s not going to go through.
So we always have to make sure to emphasize to our patients that they file their taxes on time because when they go into CRA they have your income and they can renew your application. Deductibles are paid quarterly, roughly 1% every quarter. Any unpaid deductibles get accumulated quarterly within the TDP policy years. So let’s say for quarter one I haven’t paid my deductible it does get carried over into the next quarter, and next quarter and next quarter. Whatever is not paid come the new Trillium year goes back to zero. Some patients ask “Will I be issued a bill to pay my deductible?” That won’t happen. It’s a sort of pay as you go plan, think of it that way.
Deductibles are paid when purchasing medication at the pharmacy with your health card. So you have to let your pharmacy know that you have Trillium. This is just an example. This is the grid so you can have an idea of what it is. So let’s say my income is here, my household income is here and I have a family of four so roughly your deductible will be divided by four within this amount. Within this amount your deductible is quarterly, once you fulfilled your quarterly deductible within the quarter and from that day on until the end of the quarter as long as the medication is covered by Trillium, then you don’t have to pay anything regardless of how much the medication costs. They just have to make sure that the deductible that they are fulfilling are for medications that are covered.
So let’s say I have a medication and it’s not covered by Trillium and I can’t get it covered, if I pay for that that would not be counted towards my deductible, so it has to be medications that are covered. That’s why we highly recommend that when a patient is filling out a Trillium application that they go to a M.R.S. Or social worker because the very first time when you do an application you can pick any start date within the range of August 1st to July 31st of the following year. The reason why it’s important to pick a good start date is because your deductible gets prorated. A lot of the time when the application goes in with an August start date it’s by default.
If I put in an application saying August 1st not knowing when my deductible will be, even though I am starting treatment now, I’m still incurring the deductible from August 1st until now which, we are in quarter 3 already. So just make sure that it’s very, very important with the start date. Only when you first submit your application can you select a start date. Subsequent renewals will always be August 1st of that Trillium year. The other thing with oncology medication and its cost. A lot of the medication now have what is called a Patient Assistance Program.
It depends on the medication, financial income of the patient, indication of use for this on label, off label. Patient Assistance Program may be able to help with the private insurance co-pay or the TDP deductible assistance. It really depends on the program depends on the drug so it’s not for all medications.
And sometimes they may be able to provide bridging. So let’s say a patient has to start medication today, but the paperwork that’s required is quite lengthy so we may be able to access the Patients Assistance Program and ask them to bridge until they get coverage. And when all else fails there could be compassionate supply. It varies. Not all programs have that and not all medication is applicable.
This is just drug coverage at a glance. Just to let you see how this actually works. I know this looks complicated but this is what we do every day. So drug coverage right here is private, the general benefit, the special authorization. It actually goes into much more detail that we don’t have up on the chart here. If we get into the knitty gritty it would be like four page charts. This plan allows for online billing. This means the pharmacy can charge the card directly.
This is a plan that needs to be paid this means that the patient has to fork up $10 000 dollars every month and wait for the insurance company to come back in a month or two to reimburse them. So these are the things that are becoming more and more important that we have to pay attention to. And if they don’t have private insurance or insufficient private insurance we can enrol them into Ontario Drug benefit program. If they are senior they are already enrolled. Come the following month on the first day starting on their birthday.
If they are not a senior they fit under any of these criteria. So these are the things we look at. This is an over view of the drug coverage.
It may get complicated so that’s why we’re here. So how can the MRS help you? We assist patients in navigating private insurance and appeals so sometimes we get patients who say they don’t have any private insurance, but in talking to them we realize even though they are on disability their insurance continues. We have found quite a few cases like this. They have been paying their premium without knowing. So we have to make sure that we investigate. And with PSHC plan, the federal plan and retirement plans, the spouse will always be covered even though the plan member may have the disease, the spouse member will always be covered. So that’s another thing we have found with the patients as well.
So we have to look into the insurance in detail. Assist patients with Trillium applications. I can’t stress enough the importance of the MRS or social worker to go through the application with the patient to make sure that the information is complete. Because once it’s submitted for appeal it is difficult to modify.
We also assist clinicians with special authorizations with private insurance and also exceptional access program and we also assist with the follow ups. Because there are some physicians that prefer to do it on their own. Assist patients with the Patients Assistance Program and to make sure that everything is coordinated. So the key is coverage optimization. Its not just about getting coverage but coverage optimization. The reason why I really focus on this is that I had a patient where they had $1000 as a family maximum. He was very young and was prescribed a medication that cost about $7000.
The doctor wanted him to start even just for a week to see how he responded and to go from there. He decided not to take medication because he wanted to save money for his family because he hand a 6 month old and unfortunately he passed away. From that point I realized how important not just to think of the patient but the family as a whole. It started with one person, with me. Here is Dianne but she went on mat leave so we put a baby picture here. Shirley is our 3rd MRS. Then Maryanne joined our team last year and also Charlene Lord. So we are all here to help you.
Our general phone number is here x2830 which is the triage line. This is our general email which gets to all of our MRS. We encourage you to use this email and this is our fax number. The other thing we want to talk about is, it really makes our job a lot easier when the patients are filling their medication at the Outpatient Pharmacy because we work directly them to ensure that patients can get access to medication immediately because if there are any billing issues.
We can see their system easily we can fix things immediately. They are located on the main floor, next to the Blood lab. Pharmacists there specialize in oncology medication, and there are private counselling units. Their oncology medications are readily available at this pharmacy. This is very important because staff at an outside pharmacy where the staff at the pharmacy were denied because they did not want to open the bottle with Chemotherapy medications, they didn’t want to put their staff at risk. So we have the facility here to facilitate that and there is an independent double checking system.
All proceeds go back to the hospital. The last thing is their complimentary next day delivery. Because it may take time to fill. They are open Monday to Friday 9 – 5:30 but closed on the weekends. We are located on the fourth floor Room 104. This is how you can find us. If you get off the floor on the fourth elevator follow the sign for the Medication Reimbursement Office, go through the grey doors, and go straight down the hallway past the washroom and you’ll see our office on the right hand side.
The key message to take home is: delaying coverage can result in delaying treatment. If a patient is starting treatment, feel free to refer them to us and we ll look into coverage for them. We can check coverage without a specific drug in mind. Phone calls and messages will be addressed within 72 hours. And that’s it!.
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