Greetings!
If patients require a new class of expensive drugs called "biologicals", it can be very challenging to access these drugs and find the funding to pay for them.
These smart drugs, such as Rituxin manufactured by Roche, can provide dramatic benefits to patients with serious diseases such as rheumatoid arthritis, colitis and cancer.
The average cost for a biological is $65,000 per year.
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| The Process and Your Advocate | |
Gord had both lymphoma and chronic leukemia. Because he had two diagnoses, he did not meet the single diagnosis requirement of the provincial drug plan. As a result, his Rituxin was not covered.
Acting as Gord's advocates, his team at Rupert Case Management (RCM) discovered, after reviewing the details of his private drug plan, that Rituxin was covered. However, there was a political problem with infusing privately paid Rituxin at the hospital. It took some creative negotiations with the senior staff in order for Gord to receive the Rituxin.
The role of the advocate is to represent the patient's interests in a system that is complex, confusing and at times adversarial.
Here is how the process works:
A prescription written for a biological when the patient is in a hospital is dispensed in the hospital pharmacy and is often paid for by the hospital's budget. However, the hospital pharmacy may direct the patient to fill the prescription at an outside pharmacy. This creates a complex situation known as 'cost shifting' that occurs when moving costs from the public to the private sector and often back again. The patient may be caught in a confusing web of beaurocracy.
A prescription written for a biological outside a hospital is sent to a specialty pharmacy. This will trigger a prior authorization process requiring that the pharmacist or prescribing doctor call the drug plan for approval. A pharmacist at the drug plan will assess the prescription and the indications for its use and either approve or reject the prescription.
The role of the advocate is to represent the patient's interests in the interaction with the private or public drug plan. The advocate must provide hard medical evidence that the biological is needed and that older less effective drugs are not appropriate. |
| To Start the Conversation Call 800-620-7551 | |
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Biologicals can be essential in helping patients to recover or survive. Patients will benefit from having an experienced advocate such as Rupert Case Management (RCM) representing their interests throughout the treatment process.
Raymond Rupert MD. MBA.
Rupert Case Management Inc.
1006 Avenue Road
Toronto, ON M5P 2K8
direct: 416-488-9412 ext. 103
24*7: 800-620-7551
fax: 416-981-8870
cell: 416-543-6514
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