Patient assistance program primer

Pharmaceutical company-sponsored patient assistance programs (PAPs) are often thought of as financial support to patients. While many PAPs offer some form of financial assistance, there are many additional types of assistance that they offer patients.

Consider this: a new breakthrough complex biologic drug is approved by Health Canada and must be infused under medical supervision, often in a hospital. Who pays for such treatments? This adds complexity for private plans whose group contracts exclude drugs administered in a hospital.

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Many insurers consider these “insured hospital services” under the Canada Health Act and believe that the hospital should fund them. Private plans will decline the claim if the drug is infused in a hospital but will pay for treatment if the drug is delivered in a private infusion clinic.

Because hospital or government funding decisions for new drugs take some time, PAP-funded private infusion clinics are often the only way patients can access a new Health Canada-approved drug.

Trying to navigate private drug plan coverage is challenging on a good day but can be particularly bewildering when the patient is dealing with a serious illness. PAPs offer trained staff members who help patients investigate their available coverage options.

With access to a private infusion clinic, private drug plans may cover the drug but may require the patient to pay co-insurance. If a drug is $30,000 per year, some patients might not be able to afford to pay the pharmacist their 20% co-insurance (or $6,000). Some PAPs offer financial assistance because, even with private coverage, the co-insurance can sometimes be a barrier to access.

Some biologic medications have unpleasant side effects, and patients sometimes try to discontinue treatment. Some PAPs will follow up with patients after the medication is taken to provide support on how to manage the side effects and encourage adherence to the treatment.

If a new drug is known to have volatile side effects, Health Canada may require the pharmaceutical manufacturer to set up a risk mitigation program (RMP) as a condition of approval. The RMP is integrated with the PAP and may require physicians and pharmacists to take online training before they can prescribe or dispense the product, closely monitor access to the product, and track patient outcomes and adverse events.

Some medications require consultation with additional medical professionals or certain tests before treatment. Some PAPs will schedule and sequence the appointments, co-ordinate results, consult with the specialist and arrange for treatment, if appropriate. If a condition limits mobility, some programs will even arrange for lab tests or drug infusions in the patient’s home.

These programs can be a real benefit to patients, which can help the employer’s bottom line in the long run. Encourage employees to speak to their healthcare team to learn what may be available to them. DRUGCOVERAGE.ca—a guide to reimbursement for prescription medications in Canada—is another resource that employees should be aware of.

Suzanne Lepage is a private health plan strategist based in Kitchener, Ont.