drug access navigation - an insider's perspective

ODANO

Oncology Drug Access Navigators of Ontario

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Objectives

• Who is ODANO?• Backgrounds• Regions • Our referral process – why this role

is needed• Benefits to the patient• Benefits to the Centre• How we work together

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Objectives

• Challenges / Wish list

• Public coverage

• Private coverage

• Case studies

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ODANO – Oncology Drug Access Navigators of Ontario ODANO is a provincial organization

of Drug Access Navigators founded to provide support, advocate for members, educate and share resources with existing and new members in order to maximize the appropriate funding for all oncology patients.

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Mission Statement - ODANO

Every ODANO member has the resources and the knowledge to ensure that every oncology patient has access to the medication they need.

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Backgrounds

Currently our membership is over 50 members

Pharmacy technicians Administrative Assistants Social Workers RN’s Pharmacists

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List of Cities – sample

Barrie Grand River Hamilton Kingston Lakeridge London Markham Niagara Falls North York Ottawa

Peterborough Sarnia Sault Ste Marie Scarborough Sudbury Sunnybrook Thunder Bay Toronto Windsor

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Navigators other Provinces Alberta British Columbia Quebec New Brunswick Newfoundland Nova Scotia

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Our Referrals - Defined

If a patient has no drug coverage we will assist with the Trillium Application Annual Deductibles are based on Household

Net Income Divided into quarters Approximately 4-5% of net

Apply -Track and Renew MOH - Exceptional Access Programs applications Drugs that are not listed as General Benefit

and/or Ltd use with the ODB

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Our Referrals - Defined

Apply to the Special Access Program – Health Canada For drugs that have not yet received

NOC – Notice of Compliance Not funded by the Province Help patient find $ for treatment

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Our Referrals - Defined

Investigate funding through Private Insurance Carriers 3 way calls between the patient –

Insurance Company and Navigator Prior Authorization Forms Exceptions to the formulary Renewals are required every 6 – 12

months for many drugs Appeals

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Our Referrals - Defined

Sometimes we have to use a combination of Private and Public plans to fully fund the drug

Enroll patients with Pharmaceutical Company Patient Assistance Programs to investigate what kind of programs are available to help patients

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Benefits to the patient

We are : Patient advocates

Remove the financial burden from the patient

Reduce the patients / families anxiety

Assist patients to access coverage Explore all possibilities

Assist patients with their insurance forms

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Benefits to the Institution Centralized program

One stop shopping

Resident expert investigate

Part of the treatment team

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Treatment Team

Physician

Drug Navigator

Nurse

PharmacistSocial Worker

Patient

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How we work together

Physician makes a referral to Drug Access

He/she will ask us to investigate various treatment options

The Physician makes the final decision on what treatment will be used

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Public Payer Issues - Wish List Quicker processing of applications by

the Trillium Drug Program Can take 6+ weeks Delays in treatment

Can affect treatment outcomes

Quicker response time by the MOH -Exceptional Access Program Currently applications are taking 4+ weeks Should be 1-2 weeks

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Private Payer Issues – Wish List 1. Private payers deal directly with the

DAN on behalf of patient Today most carriers will not speak with

the DAN without having to have the patient on the line.

Recognized as a member of the patient’s health care team and patient’s advocate

Dedicated contact or team that we could deal with directly with the insurance carrier

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Private Payer Issues – Wish List 2. Would like to see quicker decisions

(5 business days) Because these are cancer treatments,

they can be a matter of life and death Sometimes take up to 10 days (almost

two weeks) to get a response

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Private Payer Issues – Wish List 3. Dedicated management contact to

escalate issues if necessary. When DAN’s are given incorrect

information or the case has to be escalated with the payer organization.

Difficult to be transferred to a supervisor by the call centre representatives.

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CASE STUDIES

Case Study #1

Newly diagnosed breast cancer She has private insurance Will receive 8 cycles of adjuvant IV

chemotherapy Requires supportive medications

at a cost of $19k – duration of treatment

Referral is made to DAN22

Investigation into her private plan Drugs are covered at 100% Plan has an Annual Maximum of $5000 Pay direct card

That’s only adequate coverage for less than 1/3 of the cost of the medications she’ll require

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Max out her private plan Assist patient with Trillium

Application Arrange to have application

expedited Transition from Private Insurance to

Trillium (Public)

Adequate funding has been secured for all of the medication required at little cost to the patient

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Case study #2

Patient has been prescribed an oral chemotherapy treatment

Cost is $4k / month Referral made to DAN

Action Plan

Investigate - private insurance Covered at 100% Patient has a pay and submit plan Patient has no means to pay

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DAN ask the Insurance company if they can make an exception

Application is denied Contact the Pharmaceutical Company

Patient Assistance Program to investigate what programs are available to help patients

They offer “An Agreement to Pay” Our request is accepted

The patient can proceed with the treatment

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Case Study #3

Patient with disease progression is referred

Patient has private insurance The medication is not a benefit under

his plan Make an application to the Insurance

company for an Exception to the formulary

Application is denied 27

The drug is NOT publicly funded Only available to patients with

private insurance No other treatment options for this

patient

Patient continues to be followed by the Oncologist without treatment…

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Summarize• Who is ODANO?• Backgrounds• Regions • Our referral process – why this role is needed• Benefits to the patient• Benefits to the Centre• How we work together• Challenges / Wish list

• Public coverage

• Private coverage

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Canadian Cancer Survivor Network

Biography Michele MacDonald

Drug Access Facilitator

Juravinski Cancer Centre

Hamilton, Ontario

Treasure of Oncology Drug Access Navigators of Ontario (ODAN) O

Has worked at the Juravinski Cancer Centre since October 2007. She started her career in pharmacy working at Shoppers Drug Mart while going to Mohawk College pursuing the pharmacy technician diploma.

After finishing school while still working at Shoppers a job was offered working at the Juravinski Cancer Centre mixing chemotherapy which she continued until 2008 when the drug access job came available.

Michele has also worked at Mohawk College as a teaching assistant in the sterile IV lab course.

Duly licensed as a member of the College of Pharmacists and entitle to practice as a Pharmacy Technician.

Member of the Ontario Pharmacists Association.

Registered with the Pharmacy Examining Board of Ontario

Treasure for Oncology Drug Access navigators of Ontario (ODAN) O

Cancer I was diagnosed with breast cancer on November 4th,

2013. I will never forget the day I heard that news. I was numb, shocked, afraid, and devastated.

How can this be happening to me? It happens to other people not me? In a matter of days my life turned into a complete roller coaster of doctors appointments, ultrasounds, X-rays, MRI, and no more work.

I didn’t have time to process what was happening and I was leaving in 2 days for Cuba. Do I go? I did as I figured it was better to wait for results from the biopsy in the sun then to stew about it at home in the cold.

Cancer C – Courage, Courageous

A – Advocate

N - Never give up

C – Celebrate Life

E – Enthusiastic

R - Research

My Journey The last year and a half has been just a blur, one thing after

another. I remember thinking this will be easy I work here, I know what’s going to happen, and it will be fine!! Boy was I wrong I had no idea what I was in for. You have no idea until your on the other side.

First there was the biopsy results, positive for invasive ductal carcinoma. I was blessed at that point that I was given an appointment with the surgical oncologist the next week. A bilateral mastectomy came next and I was definitely not prepared for that. Next came 4 months of chemotherapy as 3 out of the 6 lymph nodes came back with microscopic cells. All I could think about was Oh gosh I’m going to lose my hair!!, not the fact that within weeks I would have toxic drugs running through my veins. Next came the Axillary Node dissection, a procedure in which the next level of lymph nodes are removed. Negative, whew what a relief. Finally some good news for a change. Radiation followed everyday for 6 weeks, I really found out how much I did not know. I was exhausted mentally and physically.

During the whole journey I was also seeing the plastic surgeon who put chest expanders in at the same time as my mastectomy so that I could go through the expansion process. This process includes going to see the doctor every 2 weeks so that he can inject saline into the expanders to gently expand the remaining skin to make room for implants. This unfortunately did not go well. Due to the tissue damage from radiation my skin would not stretch and was incredibly painful. The decision was made for me to undergo a 3rd surgery called a Latissimus Dorsi Flap surgery. This entails removing tissue, muscle and skin from your back and adding onto your front breast area in order to make room for expansion. This was by far my greatest challenge, I was in quite a lot of pain and came home with 3 drains. Homecare nurses would come every 2nd day to check on the incision and drainage.

3 weeks after this last surgery I returned to seeing the plastic surgeon for saline injections into the chest expanders. I am totally relieved that now my skin is stretching out wonderfully and once I get to the desired breast size I wish to be the injections stop.

2 months later I will finally get the implants, we are hoping for July or August, then I get to go back to work. It will almost be 2 full years that I have been off work.

Drug Access Working as a drug access navigator my first

concern was what is going to be the drug costs?

I was extremely lucky my husbands coverage was 100% with no co-pays or prior authorization forms

I counted my blessings that this would not be a worry.

When treatment was completed I was shocked at the total amount of prescription costs.

Drug access navigators are definitely a necessity.

What have I learned?

Breast Cancer is the 2nd leading cause of death in Canada.

Breast Cancer death rates have gone down in every age group. This reflects the impact of screening and better treatment options.

No one is safe from this disease!! If it happened to me it can happen to you

Cancer does not discriminate.

Working in Health Care

Working as a drug access facilitator and going through cancer myself will allow me to be able to do my job better when I return to work. I have always tried to look normal, do my make-up, dress nice, and have a smile on my face. Even though I felt terrible, it didn’t mean I was fine. I will definitely have more patience for people because you never know what may be going on with them.

My co-workers were the best. It was a very heartwarming experience to see how much I was cared for. Not one chemo session went by where I didn’t have the staff coming to cheer me up. Working in the environment that we do certainly does make the journey go easier but it is still overwhelming.

Final Thoughts I came from a pretty close family, but it

definitely made us closer as a whole and really makes you enjoy every minute you have.

Ask for help. Don’t wait for offers. Other people can cook for you, clean for you, do laundry, errands or banking. Only you can fight the cancer!!!

I learned that I can put myself first, this is the first time in my life that I can honestly say I learned to do that.

Focus on the present and use your energy to focus on treatment and getting better. Dwelling on what you can’t change will only cause you to lose the ability to cope.

You can sit and cry or feel sorry for yourself, or you can choose to be strong and positive. Trust me, it will make you stronger, more positive and change your outlook on life. In some ways, cancer was a good thing for me. A perfectionist who now can slow down, relax, and enjoy life.

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QUESTIONS…

Canadian Cancer Survivor Network Contact Info

Canadian Cancer Survivor Network1750 Courtwood Crescent, Suite 210Ottawa, ON K2C 2B5Telephone / Téléphone : 613-898-1871E-mail jmanthorne@survivornet.ca or mforrest@survivornet.ca Web site www.survivornet.caBlog: http://jackiemanthornescancerblog.blogspot.com/Twitter: @survivornetcaFacebook: www.facebook.com/CanadianSurvivorNet Pinterest: http://pinterest.com/survivornetwork/