Obligatory—this is not medical advice
A bugaboo amongst oncologists, and this is not sarcoma specific, is the lack of transparency in prescription drug prices. There are some more intricate aspects to this on which I am perhaps not entirely qualified to comment. Rather, what I will describe is the physician experience—something that I am familiar with.
On the day of our visit, the patient, their family, and I will have a discussion regarding their condition, goals, values and how we can reconcile each with available therapies known to be active for their condition. This is an emotionally intense conversation that involves many aspects, personal, interpersonal, or otherwise. By the end of the visit, we have determined our course of action, and what is appropriate for the patient. This is done, in our office and others throughout the nation, by world class experts in the field.
The ultimate outcome of that visit is orders, which are a reflection of the conversation. For patients with new diagnoses of gastrointestinal stromal tumors (GISTs), this could be imatinib and the requisite labs and imaging. These orders are sent to the patient’s pharmacies, preferred imaging centers, and laboratories. The cost to the patient and physician is unknown at this point, and some would argue intentionally so. It, sadly, is something that we find ourselves a victim to at times. If a patient fills or receives a medication without permission from a payor, they may be on the hook, and there is no incentive for insurance companies to cover something that has already been paid for. The payor probably has not evaluated the case, nor are they legally obligated to do so initially in many instances.
Some alternatives to the dependency the retail pharmacy/insurance paradigm have arisen. One that I will use is CostPlus Drug Company.1 I would venture to say that most readers have probably seen Mark Cuban extolling the virtues of this company within the last few months. I don’t agree with all of his claims, but I do know that for approximately half of my patients taking imatinib, it has significantly reduced their out of pocket costs. Let’s explore further.
What is it?
CostPlus Drug Company is a mail order pharmacy that will fill generic prescriptions with a cap (as advertised) on margins. As an entity, it exists within most electronic medical records, as an alternative pharmacy to which a doctor might send a prescription. A physician may input it as a preferred or target pharmacy for a prescription, and send it there.2 For the prescription, under additional information, the provider may include the patient name, date of birth, and phone number. They have multiple types of cancer medications that are generic and can be less expensive than filling directly with another specialty pharmacy.
I noticed that a recent addition is abiraterone for prostate cancer. Some may quibble about the dosing, but a phase II study published in JCO demonstrated that 250mg can be suitable with the right diet.3 For imatinib, which is commonly given at the 400mg daily dose for patients with GISTs, the cost is a little over 100 dollars every 3 months with shipping and other fees. While I do contest the retail price listed, anecdotally, I will say that 400 dollars annually for imatinib, as opposed to in excess of 5000 dollars/year reported by some of my patients at retail, is much more reasonable. This is a drug that’s been available for more than 20 years. See image capture below.
Other Medications for Patients with Cancer
Medications for nausea, for instance, can likewise be cheaper depending on the insurance plan a patient has. The standout here, as I see it, is ondansetron ODT, which can be very expensive for some patients if purchased from a retail pharmacy.
Problems
There are certainly times when patients may have a lower out of pocket cost when filling a medication utilizing their insurance. We should be communicating well to ensure that the cost to patients is the minimum. Some may argue that prior authorizations can sort through this, but, again, the incentive for an insurance company to overturn a denial is not there.
Medications ordered through CostPlusDrug company do have a turnaround time. They are shipped from a location to a patient’s home. There are multiple implications to this.
Patients have to be able to wait to start the new medicine
Things in cancer care can be needed quickly, if not immediately
Patients need a reliable address at which to receive the medication
Patients need to register for an account online
Some degree of internet savy is required
Aspects of this account cannot be changed
Patients may have to file with their insurance company to tabulate out of pocket costs towards their deductible
Conclusions
Despite the above issues, utilizing this pharmacy has helped a good number of my patients avoid unnecessarily burdensome drug prices. I’m encouraged by ability of CostPlusDrug company to come in and change the delivery of a fundamental aspect of healthcare, prescription drugs. It has been disruptive in a good sense. My sincerest hope is that it continues to act in a way that is favorable for patients. For the time being, it is part of my discussion at our new visits for patients with applicable medications.
https://www.acpjournals.org/doi/abs/10.7326/M22-0756?journalCode=aim