Medication Assistance

The American Organ Transplant Association is seeking funding for a Medication Assistance Program. Funds can be provided in the form of a grant from a Foundation, individual, corporation, or other group.

Program Objective

To provide $250 average support per month for transplant medications for 75 transplant patients who are in need and on an ongoing basis.

Historical Overview & Need

Dramatic improvements have occurred in organ transplantation. However, all patients, with the exception of the rare recipient of a transplant from identical twins, must take immunosuppressive medications as well as a number of other medications as may be needed based upon a patient's clinical condition.

The Original Medicare Plan, with only a few exceptions, has provided outpatient prescription drug coverage for a specific time. Many commercially managed care and medical insurance benefit Payors often apply prescription drug limits or offer plans with a high dollar out-of-pocket expense to members.

There are limited options for the payment of expensive immunosuppressive medications which negatively impact patients' lives. The high cost of meds also plays a role in medication nonadherence, a result of many transplant failures.

The question of how to pay for expensive transplant medications, such as immunosuppressive medications, is key to the success of an organ transplant and has plagued the United States Congress for the past quarter century.

Congress has acted several times since 1972, as follows:

In 1972, Congress made treatment of end-state renal disease (ESRD) a unique entitlement under Medicare.

In 1984, Congress passed the National Organ Transplant Act authorizing payment for immunosuppressive medications for 1 year after a Medicare covered renal transplantation.

In 1991, Congress authorized payment for transplantation and immunosuppressive medications for heart and liver recipients.

In 1992, Congress authorized an extension of the time limit for immunosuppressive drug coverage from 1 to 3 years.

In 2002, Congress authorized Medicare to cover immunosuppression for the life of the patient if they had Medicare coverage at the time of their transplant.

The need to assist patients with their medications is multi-fold:

• Even patients with adequate health insurance find that organ transplantation is an expensive therapy. Many patients are faced with the need of a transplant and soon discover their medical policy has excluded or limited coverage for organ transplantation and necessary medications.
• Adding the cost of their medical premium, travel, lodging, medications, follow-up and other medical expenses to their deductible and coinsurance fees, provides an expensive result for individuals with insurance. For patients with low family income, these medications and health fees directly compete with the provision of other basic necessities.
• Many low-income jobs cause patients to earn too much to qualify for financial help nor allow for qualification into a pharmaceutical assistance program. Yet, they earn too little to afford private insurance. Many programs are in place to assist patients; however, many have limited access, tough requirements for participation and provide only temporary support.

Category of Patient Need

Five categories of patients have been identified who need medication assistance. Each of these categories has been ranked in order of need with the first demonstrating the highest level of need.

Group One:

The demographics of group one would represent non-resource patients. Included would be t due to unemployment, due to illnesshose patients without insurance coverage and those individuals no longer eligible for Medicare coverage. Many individuals in this group are the working uninsured.

Group Two:

Included in this group would be those patients who have Medicare insurance but are unable to afford the deductibles, coinsurance and co-payments. Transplant patients shopping for supplemental insurance plans to help with these expenses will find that the supplemental plans have their own deductibles and monthly costs to meet as well as a medical underwriting process that leads to the denial of their participation. With the demise of the Medicare HMO plans, the medical underwriting process has been waived, but only until March 3, 2001.

Group Three:

This group is characterized by being able to afford some of their medications but not all of the medication costs. For example, a patient may be able to absorb and afford the cost of four medications but not all eight needed in their transplant therapy program. Many individuals in this third group have medical insurance. Many, however, may not have coverage or may have benefit limitations on outpatient pharmaceuticals.

Group Four:

The fourth group of individuals are those covered under the limited medication benefit provided by the state Medicaid program. Title XIX created the Medicaid program to pay medical bills for low-income persons who have no other way to pay for care. The Medicaid program pays for 3 prescriptions a month. However, many times these patients are on 5 to 6 medications. With the limited benefit, patients on Medicaid are unable to afford the additional medications needed.

Group Five:

The fifth group are those in need of a short-term supply of a particular transplant medication. Often people in this group are needing only a week or a few days' supply until their mail order arrives or they become eligible for their monthly allotment.

Identification of Patients in Need

Patient need shall not be determined by AOTA. AOTA will provide guidelines and criteria for consideration by the social work teams at each of the identified transplant centers. There will be an AOTA specified monthly amount or number of patients per month per center who are able to receive medication support. Patient need is specific and can include options of complete funding for medications to varying degrees of partial funding.

Participating Transplant Centers

A pilot study will be conducted in Houston, Texas. Following implementation of the medication assistance program in the Houston area, expansion efforts will begin with the identification of additional transplant center participation in the State of Texas.

The pilot study will include the participation of the following transplant centers:

• MD Anderson Cancer Center
  
• Memorial Hermann Hospital
  
• Methodist Hospital
  
• St. Luke's Episcopal Hospital
  
• University of Texas Medical Branch

Medication Listing
The following is a list of those medications for which the Medication Assistance Program will support. Those noted with a "*" will allow a pharmacist to dispense generic drugs in substitution for brand or trade name drugs where an appropriate generic substitute with adequate bioavailability is available and with prescribing physician's authorization.

Program Administration

The administration of the program will be directed by AOTA and managed by an outside firm. The Healthcare Savings Card has been approached and is capable of supporting the needs of the program.

Medication Discounts

The Medication Assistance Program is designed to assist patients in need of transplant medications. The Healthcare Savings Card will negotiate with wholesale and pharmaceutical distribution centers in an effort to obtain favorable rates for the medications listed herein. Such discount pricing will allow for funding monies to go further in assisting more patients.

Distribution of Medications

Designated pharmacies are identified with each of the relationships the Healthcare Savings Card negotiates for discounted medications. Each of these pharmacies will be equipped to distribute the medications noted to the transplant patients.

Patient Identification

Patients will be provided a customized American Organ Transplant discount card. Each card will have the patient's name, identifying information as well as the AOTA logo. The back of the card will be supplied with pharmacy and vendor specific directions.

Eligibility

A report will be provided to the pharmacy benefit manager by the Healthcare Savings Card company on at least a monthly basis and more frequently as may be needed. This report will denote the patients receiving financial support as well as the dollar figure and arrangements for support. When a patient presents at a designated pharmacy, the pharmacy will query their system and locate the patient.

Funding Limits

Upon identification of an eligible member, an amount of financial support or cost sharing relationship will appear. Should funding exist, the pharmacy will provide the transplant medication to the patient as directed. Should no additional funding for a particular patient exist, the pharmacy will apply the negotiated cash pay rate for all non-transplant related medications.

Other Benefits Provided by AOTA through the Healthcare Savings Card
With the AOTA Discount card, additional benefits will apply, as follows:

• Significant discounts on ALL prescription medications whether transplant related or not.
  
• Dental Examination Discounts (Dental exams are sometimes requested by transplant coordinators for the detection of medical concerns.)
  
• $35 eye exams at participating vision centers (i.e. EyeMasters) including a discount off frames, lenses, contact lenses and non-Rx sunglasses.
  
• Cash payment to a network of medical physicians at the Medicare allowable government rate.

Funding Needs for Medication Assistance Program

The average cost of immunosuppressive agents alone may range from $10,000 - $14,000 per year for one kidney recipient. The following outlines the average number of patients and monthly support that is needed as estimated in the Houston area based on a sample survey of select transplant centers.

75 Patients

• $250 average support per patient per month. The need for specific patients may be higher or lower than the stated figure.
  $ 18,750 per month
  
• Administrative Fees calculated at 2%
  $ 375 per month
  
• Annual Program Costs
  $ 229,500

Investment Rate

• 9% return
  

Amount of Funding Needed to Allow for on-going support of the program

• 2.5 million dollars

Funding Sources

Initially five funding sources will be solicited for support of the funding needs identified for the program. As well and as appropriate, large contributors to the funding of the program will be able to display their company logo on the member's identification cards.

The five sources are outlined here:

• Tobacco Settlement Funds (Texas)
  
• Corporate Sponsorship
  
• Individual and Estate Sponsorship
  
• Grant Proposals
  
• Pharmaceutical Industry Pooling