Patients in Oklahoma receive specialty fertility medications far more quickly and at significantly less cost than they did before, thanks to streamlined prior authorizations (PAs) and access to the federal government’s 340B Drug Pricing Program.
These improvements are a result of a partnership between OU Health University of Oklahoma Medical Center and Clearway Health, a Boston-based consultancy that helps health systems strengthen their specialty pharmacy offerings.
The need for more affordable fertility treatments is acute. Approximately 9% of men and 11% of women of reproductive age in the United States have experienced fertility problems, according to the National Institutes of Health. For many such individuals, the cost of fertility medications can be a major roadblock. A single cycle of in vitro fertilization can cost as much as $30,000, according to figures cited by several fertility clinics. Unfortunately, fertility medications often aren’t covered by insurance, resulting in out-of-pocket costs that could exceed $10,000, depending on the fertility drugs and services provided, according to KFF. At OU Health, the main strategy for lessening the resultant financial toxicity was to leverage the organization’s status as a safety net hospital that has access to 340B drug pricing. Working with Clearway Health to implement the strategy, OU Health saved patients $410,205 in fertility medication costs over five months, noted Jigar Thakkar, PharmD, MBA, MHCDS, FACHE, the chief administrative officer for OU Health.
As an example, an OU Health patient on a fixed income received in vitro fertilization for $400 per treatment thanks to such programs, instead of the initial $2,400 charge.
Avoiding Treatment Delays
OU Health can secure PA approval in less than a day while one estimate of the industry standard is at least two and as many as 31 days, Dr. Thakkar said. The fertility program also secured $995,000 in patient assistance funds from July 2022 to 2023.
Helping Hopeful Parents Navigate the Fertility Treatment Maze
Many potential parents cannot access the fertility support offered by OU Health and Clearway Health. That’s where fertility specialist Natasha Stamper, PharmD, comes in. Dr. Stamper, the founder of Fertility Pharmacist LLC, in Lewiston, Idaho, coaches clients on ways to afford medications and how to store them properly.
Dr. Stamper often works with employers who provide health insurance for fertility treatments to help them defray the high costs of this care. Done correctly, the benefit to patients can be significant. In fact, “some of my clients will actually work at Starbucks just for their fertility insurance coverage,” Dr. Stamper said.
Navigating fertility coverage can be daunting, she stressed. Although many medical insurance plans cover oral fertility medications such as clomiphene or letrozole, fewer plans cover intrauterine insemination and even fewer pay for in vitro fertilization (IVF) or follicle-stimulating hormones such as follitropin alfa (Gonal-F, EMD Serono), Dr. Stamper noted. IVF often requires egg freezing, which can cost up to $5,000 per freezing cycle, she said. Anyone who must pay for IVF treatments or follitropin alfa out of pocket can sometimes access rebate plans based on income, or discounts for veterans if those apply, or they can cold-call different specialty pharmacies to see which will provide a treatment for the best price. But wading through these options can be time-consuming.
“I wish there was one application people could use to apply for everything related to fertility, but unfortunately that doesn’t exist,” Dr. Stamper said, which is why she points clients to financial resources that she discovered herself when aiming to conceive with IVF in 2014. Compared with that time, Dr. Stamper said, today social media sites such as Instagram and TikTok make it easier to share this information.
Once they’re paid for, fertility medications have specific storage requirements. Dr. Stamper noted that some medications must be refrigerated, others must be shielded from light, and any injections must be handled carefully due to the risks of sharp needles. A woman trying to conceive may need medications in each of these categories, Dr. Stamper said, making appropriate storage and handling critical.
“My goal is that all my clients know how to use their medications safely. And we certainly don’t want any medication to spoil because it wasn’t in the refrigerator,” Dr. Stamper said, adding that this would be a tragic outcome after working so hard to get the treatments in the first place.
“I think the cost of medication is what stops many people from pursuing fertility treatment,” Dr. Stamper said.
—Marcus A. Banks
In addition, more than 2,000 prescriptions per month are mailed at no charge to patients who need them. Much of this is funded through new specialty pharmacy revenues; before the Clearway Health partnership, only 8% of OU Health patients received specialty pharmacy services, whereas 45% do today.
Wide Scope of Operations
Alex Pham, PharmD, MBA, Clearway Health’s vice president of client services and strategy, said these types of strategies and process improvements can be applied across a wide practice range. “We work alongside hospitals and other healthcare communities to strengthen their specialty pharmacy programs from any stage.”
OU Health’s next steps, again partnering with Clearway Health, are to research whether its various specialty pharmacy initiatives reduce overall healthcare spending by improving patient outcomes.
“As you’re thinking about your specialty program, it’s about much more than capturing scripts,” Dr. Thakkar said. “It’s truly about transforming your clinical care model.”
The sources reported no relevant financial disclosures beyond their stated employment.
This article is from the April 2024 print issue.