Hematopoietic cell transplant (HCT) is a potentially curative treatment modality for patients with hematologic malignancies, but it can be associated with significant financial burden and toxicity due to increased medical expenditures (i.e., prescription drugs). Prophylactic anti-infective medications are an essential component of allogeneic hematopoietic cell transplantation (allo-HCT) and help mitigate early post-transplant complications. Although these prophylactic anti-infective medications are essential, insurance barriers (i.e., prior authorizations, denials, and high out-of-pocket costs) limit access for many patients and may result in reduced access to allo-HCT. The objective of this study was to evaluate the degree and severity of insurance barriers in a large cohort of allo-HCT recipients to characterize the patient populations and transplant types experiencing these barriers. Medical records of patients who received high-cost medications (mold-active triazoles and letermovir [LTV]) during their first allo-HCT (1/1/20 - 5/1/22) were evaluated for insurance type, ancestry/ethnicity, and stem cell source. Pharmacy records were used to analyze insurance barriers in the first 100 days post-transplant. Patients were categorized as having Minimal to None, Moderate, or Extensive barriers. In the azole (n=287, voriconazole n=162, posaconazole n=64, isavuconazole n=61) and LTV (n=191) groups, the median age was 61 (range 19-81) and 61 years (range 22-81), respectively, with 44% female overall. In the azole group, 60% of patients had Minimal to None, 23% had Moderate, and 17% had Extensive barriers, while in the LTV group, 39% had Minimal to None, 28% had Moderate, and 33% had Extensive barriers. Seventy percent of patients had private insurance. The proportion of private vs. governmental insurance was equal in each barrier category in the azole group; however, among patients receiving LTV, those with government insurance were more likely to fall into the Extensive barrier category. Extensive insurance barriers impacted 17% (49/287) of patients prescribed high-cost azoles. Among these patients, 31% had projected costs exceeding $1,000, 78% required financial assistance (20% copay assistance card, 12% drug manufacturer assistance, 62% internal financial assistance), and 80% required more than 60 minutes of PharmD time to coordinate financial resources to make care affordable, compared to just 1% of patients with minimal/no barriers. Among patients prescribed LTV, one-third (63/191, 33%) faced extensive insurance barriers with 57% of these patients having projected costs exceeding $1,000, 98% required financial assistance (34% copay assistance card, 45% manufacturer assistance, 21% internal financial assistance), and 68% required more than 60 minutes of PharmD time, compared to 8% of patients with minimal/no barriers. For both the azole and LTV groups, by univariable analysis, insurance type, ancestry/ethnicity, and stem cell source were not statistically significantly associated with having moderate or extensive barriers. Approximately half of the cohort required additional financial resources to ensure access to essential post allo-HCT azoles and LTV. Neither insurance type nor transplant characteristics predicted the level of barrier, suggesting that all patients should be assessed for financial toxicity. Pharmacists played an integral role in overcoming the insurance barriers for these high-cost medications, and work is ongoing to expand our understanding of the financial issues impacting our patients.
Keywords: allogeneic hematopoietic cell transplant; anti-infectives; financial toxicity; insurance barriers.
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