Explain High-Level Medicare Insurance and the pathways for assistance to minimize out of pocket expenses. Case Studies included.

1. Medicare
Patient Access
Barriers
Melissa L. Paige
Oncology/Infusion
Patient Access Principal Coordinator

2. Why Medicare?
By 2030, Virginia’s elderly population is
anticipated to nearly double in size, accounting
for about one in five Virginians.
Aging Population

3. • No Manufacturer Copay Cards, Only
Grants/Foundation Support
Medicare Insurance
Overview

4. Medicare

5. Donut
Hole

6. Help for Medicare D
Pathway
Manufacturer
All-in-one Application
• Go to Needymeds.org or go
to specific Manufacturer
Website
• Benefits Investigation
• Copay Support
• Patient Assistance
• Field Reimbursement
Support
Grant Available?
Yes
• Enroll in the Grant
No
• Request to transfer to Patient
Assistance
Patient Assistance
Last Resort
• Each Manufacturer has their
own criteria
Denied
• Appeal

7. Disclaimer: The following Scenarios are examples
of cases we have ran into at our facility, and the
steps we took to find access. These do not reflect
every manufacturers process. They each have
their own separate criteria. Make sure to call and
verify.

8. • Manufacturer Application
• PA Done
• Copay Amount $2172.00
• No Grants Available
• Patient Assistance Criteria for Med D Patients
– Spend 3% out of pocket for year on prescriptions
– Currently they have only spent $200, and they need to
still spend $500 more to qualify
• Reach out to Specialty Pharmacy
– Fill enough medication to meet that $500
– Submit receipt back to Manufacturer
• APPROVED FREE DRUG
Scenario #1
Medicare D Patient on Oral (Pharmacy Benefit)

9. • Manufacturer Application
• Medication is not covered for Diagnosis
• Patient Assistance Criteria
– Denial from Insurance
– 1st Level of Appeal Denial
• Have Medication filled at a Pharmacy under the
Medicare D Benefits
– Submit for Prior Authorization
• Denied
• 1st Level of Appeal (Letter of Medical Necessity)
• 1st Level of Appeal Denied
• Application moved over to Patient Assistance
• APPROVED FREE DRUG
Scenario #2
Medicare Patient Infusion (Medical Benefit)

10. • Manufacturer Application
• Medication is not covered for Diagnosis
• Patient Assistance Criteria
– Denial
– 1st Level of Appeal Denial
• Have Medication filled at a Pharmacy under the
Medicare D Benefits
– Submit for Prior Authorization
• Approved with High Copay
• Reach out to Manufacturer
– No Grants Available for Diagnosis
– Application moved over to Patient Assistance as “Last
Resort”
• APPROVED FREE DRUG
Scenario #3
Medicare Patient Infusion (Medical Benefit)

11. Grants/Foundation
Support
Grants/Foundation Support Website
Cancer Care http://portal.cancercarecopay.org/Funds-
Available/Diagnoses
Good Days https://www.mygooddays.org/for-patients/diseases-
and-medications-covered/
Healthwell Foundation https://www.healthwellfoundation.org/what-we-
do/diseases-and-medications/
Leukemia & Lymphoma Society http://www.lls.org/support/financial-support/co-pay-
assistance-program#Available Funding
Patient Access Network
Foundation
https://panfoundation.org/index.php/en/patients/as
sistance-programs
Patient Advocate Foundation https://www.copays.org/diseases
The Assistance Fund https://tafcares.org/patients/covered-diseases/

12. Resources
• NeedyMeds
– http://needymeds.org/
– Every Patient Access Program
– Free Clinics
• Rx Outreach
– http://rxoutreach.org/
• Advocacy Connector
– https://advocacyconnector.com/
What Manufacturer? What Drug? What Form?

13. Any Questions:
Melissa L. Paige
mlp3w@virgina.edu
Any specific questions, the only Info Needed:
Payer
Drug
Diagnosis