What payers and providers need to know about reverification season
At the start of the New Year, specialty pharmacy patients have more on their mind than a few resolutions. As they fight a complex, often debilitating disease, they have to manage the mountain of paperwork and phone calls that may come with standard annual health insurance reverifications as well as potential changes in coverage.
An employer may change health plans, effective January 1. That new plan may apply a higher copay to a patient's drug or not cover it at all.
A patient's health plan may say that the patient’s prescriptions need to be filled by a different specialty pharmacy. Acceptance into a biopharmaceutical company's free drug program may expire, which means the patient will have to re-apply or find another way to pay. On top of these and other "what ifs," prior authorizations for prescriptions nearly always have to be renewed and deductibles reset to zero at the start of a new year.
That's a lot to manage for anyone dealing with prescription medications through a pharmacy as we ring in the New Year.
But can you imagine what it would be like for patients facing complex diseases such as cancer, or a rare blood disease? First-of-the-year disruptions could not only cause financial and administrative stress, but they can also delay necessary treatment. So how do specialty pharmacies providing these complex specialty therapies help patients cope during this overwhelming time?
Navigating reverification season
Specialty pharmacies work closely with patients year-round to provide education and help with prior authorization, financial assistance and medication management, among many other services and clinical care. At the start of the New Year, specialty pharmacy teams work even more diligently to ensure patients receive the continuity of care they need.
"We're prepared at the stroke of midnight on December 31st to consider every one of our patients as a brand new patient," says Paula Bickley, vice president of market access for Biologics, McKesson's specialty pharmacy serving patients with cancer and complex care needs. "We have to go back to square one. That starts with a benefits investigation."
Why continuity of care matters
Due to the high cost of specialty drugs, specialty pharmacy patients experience reverification challenges more profoundly than the rest of us.
According to an AARP Public Policy Institute report, in 2015, the annual retail cost of prescription drug therapy for a single specialty drug was about $52,486 per year¹. The American Society of Clinical Oncology reports that new FDA-approved cancer drugs cost an average of $10,000 per month, with some therapies as high as $30,000 a month². Escalating prices put strain on payers as well as impact patients' out-of-pocket costs.
The more patients have to pay for specialty drugs, the more likely they'll stop treatment. As out-of-pocket costs reach $500, the rate of abandonment increases to 41% according to one study³.
When cancer patients miss a dose of their prescribed therapy, it can lower the drug's success rate. And if they miss a dose due to a January 1 copay increase, they may face other health challenges.
"These patients are battling for their lives," says Tamara Hart, vice president of specialty pharmacy operations for Biologics. "Any delays compound their stress and anxiety. We know increased stress translates to other issues that affect not only the patient, but also their families."
By proactively helping patients through reverification paperwork and other January 1 challenges, Biologics helps to offset some of their patients' financial and personal stress. "They feel like they have a partner in this journey," says Hart. "And any time a patient feels supported and has one less thing to worry about, their chances of a good outcome improve."
How specialty pharmacies provide "white glove" service
Hart says Biologics increases its staff by 10 percent beginning in October to prepare for reverification season. By January 1, they're fully trained and working the phones.
Biologics’ patients may get the first call from a patient access services team member. "Their job is to quickly identify any change in the patients' benefits and communicate the impact immediately," says Bickley. "If a patient's deductibles reset and their prior authorization is termindated on December 31st, we quickly collect necessary information and take action to ensure continuity of care."
Biologics has a team of specialists that focuses only on prior authorizations. "They know what to submit from patients' medical charts," says Bickley. "Do we need to submit the patient's genetic testing results or a recent scan that shows the position and the size of the tumor? We work as quickly as we can to reset or relaunch prior authorization approval, advocating for their treatment so the patient doesn't experience any delay or disruption."
Another team focuses on financial support. If a patient's copay exceeds averages, they get connected to a financial specialist. Those specialists help patients secure copay assistance and apply for manufacturers' free or reduced-cost drug programs.
"Given that many of our patients are prescribed high cost cancer therapies, we end up having those conversations with almost every patient," says Hart. In 2017, Biologics secured more than $37 million in copay assistance for more than four thousand patients needing oral chemotherapy drugs.
Whether it's a drug’s price change in the middle of the year, or snow storm with expected power outages across a region which requires expediting a patient’s refill prescriptions, or simply these reverification season challenges, Biologics will find a way to overcome obstacles to ensuring continuous patient care. For example, the company works with payers during harsh winters to turn off the rule that rejects refill claims when ordered too soon. Turning off the trigger allows Biologics to refill the prescription in advance of severe weather. They'll deliver to patients anywhere, whether it's a vacation home in Florida or an RV near the Grand Canyon.
"Oral cancer patients are very mobile," says Bickley. " They don’t have to be sitting in an infusion chair to receive chemotherapy, which gives them flexibility to spend more time with family and friends over the holidays. And Biologics wants to help them do just that – live their life without worrying about the logistics. Let us worry about that! Because of this, shipping logistics, close communication and attention to detail is one of the most important functions of our business."
These details may require extra resources and definitely require a fine-tuned staff that is in chorus at all times at the beginning of the year, but for specialty pharmacies, it's priority number one to ensure continuity of care. That continuity keeps providers, payers and the entire system moving forward on behalf of their collective patients, even during blustery reverification season.
"Biologics faces almost certain disruption at this time of year," says Bickley. "As plans renew and plan sponsors move into more restricted specialty pharmacy networks, we need to watch the market closely to keep access to therapies and provide the broadest service to our patients."
1.) Stephen W. Schondelmeyer, Leigh Purvis. "Trends in Retail Prices of Specialty Prescription Drugs Widely Used by Older Americans, 2006 to 2015." AARP Public Policy Institute, September 2017.
2.) "Biologics' Patient Access Services Team Procures More than $44 Million in Co-Pay Assistance for Cancer Patients in 2016." McKesson Newsroom, May 24, 2017.
3.) Jalpa A. Doshi, Pengxiang Li, Hairong Huo, Amy R. Pettit, and Katrina A. Armstrong. "Association of Patient Out-of-Pocket Costs With Prescription Abandonment and Delay in Fills of Novel Oral Anticancer Agents" Journal of Clinical Oncology, 2018 36:5, 476-482