Drug Access Navigation - An Insider's Perspective

ODANO
Oncology Drug Access Navigators of Ontario
1

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
2

Objectives
• Challenges / Wish list
• Public coverage
• Private coverage
• Case studies
3

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.
4

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.
5

Backgrounds
Currently our membership is over 50 members
 Pharmacy technicians
 Administrative Assistants
 SocialWorkers
 RN’s
 Pharmacists
6

List of Cities – sample
 Barrie
 Grand River
 Hamilton
 Kingston
 Lakeridge
 London
 Markham
 Niagara Falls
 NorthYork
 Ottawa
 Peterborough
 Sarnia
 Sault Ste Marie
 Scarborough
 Sudbury
 Sunnybrook
 Thunder Bay
 Toronto
 Windsor
7

Navigators other Provinces
 Alberta
 British Columbia
 Quebec
 New Brunswick
 Newfoundland
 Nova Scotia
8

Our Referrals - Defined
 If a patient has no drug coverage we will assist
with theTrillium 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
9

 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
10

 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
11

 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
12

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
13

Benefits to the Institution
 Centralized program
 One stop shopping
 Resident expert
 investigate
 Part of the treatment team
14

Treatment Team
Physician
Drug Navigator
Nurse
PharmacistSocial Worker
Patient
15

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
16

Public Payer Issues - Wish
List
 Quicker processing of applications by theTrillium
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
17

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
18

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
19

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.
20

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 DAN
22

 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
23

 Max out her private plan
 Assist patient withTrillium Application
 Arrange to have application expedited
 Transition from Private Insurance toTrillium
(Public)
Adequate funding has been secured for all
of the medication required at little cost to
the patient
24

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
25

 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
26

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…
28

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
29

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.

Canadian Cancer Survivor Network
Contact Info
Canadian Cancer Survivor Network
1750 Courtwood Crescent, Suite 210
Ottawa, ON K2C 2B5
Telephone / Téléphone : 613-898-1871
E-mail jmanthorne@survivornet.ca or mforrest@survivornet.ca
Web site www.survivornet.ca
Blog: http://jackiemanthornescancerblog.blogspot.com/
Twitter: @survivornetca
Facebook: www.facebook.com/CanadianSurvivorNet
Pinterest: http://pinterest.com/survivornetwork/

Drug Access Navigation - An Insider's Perspective

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