How Pharmacists Can Help Patients Navigate Costs, Access to Breast Cancer Therapies

Insurance formularies, patient assistance programs, and financial counselors play a significant role in reducing financial toxicity and removing barriers to care for patients struggling to afford breast cancer therapy, says Tiffany Meng, PharmD, oncology pharmacist, UCSF Health.

This transcript has been lightly edited; captions were auto-generated.

Transcript

How do formulary decisions and utilization management strategies impact patient access to targeted therapies for breast cancer?

I think when it comes to formulary decisions, it's kind of 2-fold. When we're talking about formulary, the first thing we usually need to think about is what's on the insurance formulary. I work in an outpatient infusion center, so we often deal with many different kinds of insurance, depending on the patients that we're seeing. Insurance formulary will often dictate what medication could be covered for the patient and what wouldn't be, and that essentially will impact patients' access to therapies.

Generally speaking, at our institution, the billing and central authorization team work together with the insurance, dealing with appeals, prior authorization, and help facilitate peer-to-peer discussions, where the providers of each individual clinic will get involved at that point. We also have patient assistance programs that are offered by various different drug manufacturers, and we have a team of financial counselors that can try to help make sure that patients can get access to these higher-cost, targeted therapies for breast cancer.

From a pharmacy standpoint, because I work in an outpatient infusion center, generally speaking, if a medication is covered by insurance, we do our best to obtain the drug because we want to be able to provide that for our patients. As long as the insurance allows it, our health system is able to obtain it. We're fortunate in the sense that we're a lot less restrictive when handling these high-cost targeted therapies compared to inpatient setting or ambulatory care setting. Also, we help deal with patient-assistance program medications. We help run the inventory and whatnot. So that's what we do to, hopefully, do our best to help make sure that patients get access to these medications.

What are the key considerations when evaluating biosimilars for HER2-positive breast cancer treatment?

I think when talking about biosimilars, it's really important that we need to make sure they have comparable clinical outcomes and safety profiles to their reference biologics. So that way, we can make sure it is clinically safe and an effective alternative when we're swapping them out for treatment. Once we establish that it is effective and safe, and switching them out is going to be safe and continue the efficacy, then we can start considering, “okay, what's more cost-effective?”

The market now has so many different biosimilars for the same drug, and every biosimilar could have a different contracting price, whether you're talking about insurance, whether you're talking about a health system, and that will determine what the cost is. Also, certain insurance will prefer one biosimilar over the other biosimilar, and that's something that, working in a health system, we have to figure out what makes the most sense for our system. Also, being able to cover the most of what our patient population insurance would be willing to cover and what our patients can actually get access to. That's kind of how we approach it.