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Would you consider any changes to address coverage gaps that occur as a result of Medicare Part D? If so, what types of changes?
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Cost a concern for seniors
 Alan L. Robin |
There is no question that the economy is affecting glaucoma care. I have seen a slight drop in patient referrals. Because patients are less likely to come to their primary eye care provider, this delays patients coming to their referral doctors. Some patients are putting off procedures or altering their dosing schedules by taking a once-daily medication every other day or a twice-daily medication once daily. But even outside of the current economic situation, cost is a significant factor for glaucoma patients, many of whom are seniors, are retired and may be on a fixed income.
The average age of the glaucoma patient is about 65 years, and studies have shown that glaucoma patients are on four to five additional medications for concomitant conditions – not including vitamins or other supplements. And for patients on Medicare Part D, there is no guarantee of getting from one side of the doughnut hole to the other. Only about 5% to 10% of patients will make it to the second coverage level, and most end up in the hole and must pay out of pocket for prescription drugs.
For first-line therapy, prostaglandins are the gold standard, and so I will try to pick a prostaglandin that is in the patient’s program. What most people do not realize, however, is that coverage varies from plan to plan, and the tier structure varies from plan to plan. Pharmacy benefit management programs add an additional layer of complexity.
Other options include reducing, if possible, the use of adjunctive therapies. Also consider splitting out combination drugs. Instead of using Combigan (brimonidine tartrate 0.2% and timolol maleate 0.5%, Allergan), I might think about offering timolol and brimonidine in separate solutions. Compliance is better when fewer drugs are involved, but the cost difference can be significant.
Drug samples and compassionate programs from pharmaceutical companies are options for patients who truly cannot afford medication. Another alternative is laser trabeculoplasty, which is often covered by a patient’s primary care plan. If you have a patient who cannot afford their medications and you cannot keep giving them samples, surgery is definitely an option to either reduce their need for adjunctive therapy or for other medical therapy.
Alan L. Robin, MD, is an OSN Glaucoma Board Member. He is a professor of ophthalmology at the University of Maryland and an associate professor at Johns Hopkins University, Baltimore.
Strategy does not change for Medicare Part D
I do not change my management strategy for patients on Medicare Part D, but mostly because it has been uncommon for me to have a patient voice an issue with being able to afford their medications because of Medicare Part D. I do not practice in a particularly affluent area, but I think people in my practice accept that there is a doughnut hole and that they are responsible for paying it. For these reasons, I still opt for a prostaglandin front line, followed by beta-blockers, then either alpha-agonists or topical carbonic anhydrase inhibitors.
 Douglas J. Rhee |
However, if a patient makes a request or voices an issue about affording their medication, I will consider making a switch to generics, splitting the combination product or offering laser trabeculoplasty provided that those measures are appropriate for the patient.
I do have many patients who have difficulty paying for medications, but not because of the doughnut hole. Generally, these are patients who are without coverage, and that’s a whole other issue.
Douglas J. Rhee, MD, is an OSN Glaucoma Board Member. He is an assistant professor of ophthalmology at Harvard Medical School and on the faculty at Massachusetts Eye and Ear Infirmary.