By Matthew Cooper, MD, Director of Kidney and Pancreas Transplantation at Medstar Georgetown Transplant Institute.
If you have received a transplant, you’ve probably had this discussion with your transplant team, “How will you pay for your immunosuppressive medications?”
It’s an even more important question now as a new study, funded by the National Kidney Foundation, found that many insurance plans in the healthcare exchange marketplace are pushing the cost of immunosuppressive medications to patients. This means many patients may pay the out-of-pocket maximum for their medications, up to $6,200 in 2015, and $6,850 in 2016.
For many people with transplants, it may be tempting to switch to generics to save costs and your transplant. In fact, many insurance plans will require generics or will try to encourage patients to switch to generic medications.
It can get frustrating to be caught in the middle, but there are three things that patients need to focus on when navigating insurance plans and generic medications.
- Review your insurance options with your transplant team. Face it, most Americans don’t know what their insurance really covers. But your transplant team has a vested interest in you and your transplant. Part of that commitment involves working with you on your insurance coverage. Every transplant center has financial coordinators and social workers to assist you in making decisions about insurance. They are the most knowledgeable about your specific needs and what you should be looking for when you are shopping for insurance. It’s always important to know if your coverage or insurance premiums will change as you transition from dialysis to transplant. They’ll be able to help you understand copays, premiums, what is covered under each individual plan and what tier of medications you will be able to receive and afford. They will also be able to work with you on contingency plans should there be any changes to your coverage. Whether you are looking for a new policy, or reviewing your current policy, you must check-in regularly with your transplant center’s financial coordinator and social worker to discuss insurance coverage.
- Know your Medications. I’ve had patients who go to the pharmacy expecting one medication, only to receive something that looks completely different. I worry about this and the unknown switching of one generic medication for another. By FDA standards, generics are only required to have between 80-120% bioequivalence to their branded counterparts. That leaves a lot of wiggle room which can sometimes cause problems and side effects, especially if your transplant team isn’t made aware of the change. We train our patients to recognize a pill’s color, size and shape. If there is a change, you need to contact your transplant center immediately as they may increase testing and monitor your drug levels more frequently to make sure your personal level of immunosuppressant need remains appropriate. If there is a medication switch that is dictated by your insurance plan, make sure you check in with your transplant team before starting the new medication.
Any change or adjustment to medication should be assessed by a physician to look at drug interactions that could be harmful to you and your transplant.
- Generics Aren’t All Bad. However, not all generics are created equal. We have to accept the fact that generics are not going away and many insurance plans require their usage. If you haven’t already been taking generics, you will likely receive them in the future. The most important thing to remember is that you need to work with your transplant team to not only develop a plan for paying for your medications, but to make sure the medications you are taking are not going be detrimental to you or your transplant’s health. Sometimes you will need your transplant team to go to bat for you when handling pre-authorizations and conversations with medical reviewers for insurance programs. It’s unrealistic, in my opinion, to wish generics away. Without these options, many people would not be able to maintain their immunosuppressive drug regimen due to severe financial hardship it would create.