In an observational retrospective study reported in JCO Oncology Practice, Seymour et al describe a strategy used by Karmanos Specialty Pharmacy (KSP) to successfully decrease patient copayments for high-cost cancer drugs.

Study Details

The study involved data from the KSP claims data set, accessed by 13 cancer centers in Michigan, from January through December 2019. As part of the process developed by KSP to automate financial assistance applications, determination of patient drug cost of more than $100 prompts a search for additional financial assistance performed by a dedicated pharmacy assistant.

KSP maintains a large data set of financial assistance sources, including foundation grants, copay cards, and manufacturer patient assistance programs, as well as maintaining an independent Karmanos Patient Assistance Fund. The financial assistance source data set is updated by pharmacy assistants (including a social worker and claims resolution specialist) on a daily basis according to diagnosis.

Key Findings

In 2019, 869 prescriptions and 1,722 prescription fills were provided to 463 patients through KSP.

Total cost for these drugs was approximately $17 million, including approximately $10 million for Medicare patients (58%), $3.4 million for privately insured patients (20%), and $3.7 million for Medicaid patients (22%).

The majority of drug costs (98%) were paid by insurers. Of 1,722 prescription fills, 22% for 27% of all patients required financial assistance. Initial patient cost claims totaled more than $335,000. Total financial assistance through KSP was $280,988, reducing total patient copayments by 81%, and consisted of $250,818 (88%) from foundation grants (327 fills), $21,441 (8%) from manufacturer copay cards (47 fills), and $12,260 (8%) from the Karmanos Patient Assistance Fund (12 fills).

Medicare patients had higher total out-of-pocket costs vs other insurance types. Foundation grants covered more than $235,000 for 310 fills among Medicare patients. The Karmanos Patient Assistance Fund was used primarily for Medicare patients. The majority of drug costs were covered by insurers for patients with private insurance, although financial assistance was still obtained for some patients, primarily in the form of copay cards. Patient assistance programs were applied for and used at least eight times for free drug(s) directly from the manufacturer. Medicaid patients have cost-sharing subsidies with minimal copayments and required no additional financial assistance.

In a subset analysis of the first 104 prescription fills for patients with hematologic malignancies, median time from prescription to prior authorization was 0 days (range = 0–39 days) for 57 fills for patients with Medicare, 1 day (range = 0–23 days) for 30 fills for patients with private insurance, and 0 days (range = 0–48 days) for 17 fills for patients with Medicaid. Median times from prescription to drug delivery to the patient were 5 days (range = 1–40 days), 6 days (range = 1–35 days), and 7 days (range = 0–56 days), respectively.

The investigators concluded, “Twenty-seven percent of patients (22% of prescriptions fills) in 2019 required additional financial assistance for high-cost drugs. KSP substantially reduced patient cost by implementing an efficient process using additional pharmacy assistants to obtain financial assistance.”

Erlene K. Seymour, MD, of Karmanos Cancer Institute/Wayne State University, Detroit, is the corresponding author for the JCO Oncology Practice article.

Disclosure: For full disclosures of the study authors, visit ascopubs.org.