Glaucoma
The economics of managing the glaucoma patient

At a glance


• Glaucoma management costs about $2.5billion/year in the U.S
• Glaucoma meds account for an estimated 38-52% of the $1.9 billion in direct costs
• For patients with no insurance, more costly surgery is being consider as some coverage is available
• Pharmacy programs & pharmaceutical company programs may help patients bear burden of medication costs


Alcon Labs Humanitarian Services
Medications: Azopt, Betoptic S., Timolol, Travatan
800-222-8103, option 2

Allergan Patient Assistance Program
Medications: Alphagan P, Lumigan
800-553-6783

Merck Patient Assistance Program
Medications: Cosopt, Timoptic, Timoptic XE, Trusopt
800-727-5400

Pfizer Connection to Care
Medication: Xalatan(800-707-8990

Pfizer MAINTAIN Program
Medication: Xalatan
1-866-706-2400

Source: Glaucoma Research Foundation

How to ensure your patient stays compliant when they can’t afford the medication

Managing a chronic disease such as glaucoma can be extremely expensive. In the January 2008 issue of the American Journal of Ophthalmology, Nathan R. Rylander and Steven D. Vold reported that the management of glaucoma costs about $2.5 billion per year in the U.S. and glaucoma medications account for an estimated 38% to 52% of the $1.9 billion in direct costs.
The situation is made worse if patients are without insurance, pharmacy benefits or if they have reached the Medicare Part D donut hole. Fortunately, there are some ways physicians can overcome these obstacles while still giving their patients the care they need.
Douglas Rhee, M.D., assistant professor, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, says that once it’s identified that the patient cannot afford the long-term medication needed to manage their glaucoma, “We do look at alternative options— laser trabeculoplasty if it’s appropriate or incisional surgery.”
Robert D. Fechtner, M.D., professor, Institute of Ophthalmology and Visual Science, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, N.J., takes the same approach, “For patients who have no insurance, we’re proceeding with laser and sometimes with incisional surgery since sometimes those are the only treatments for which there is some coverage.”
In New Jersey, there is an assistance program where individuals who are financial-challenged, can get access to hospital-based care, he says. Known as the New Jersey Hospital Care Payment Assistance Program, the charity care is for people who are uninsured and underinsured. The hospital-based system covers surgery and not medications.
“We [glaucoma surgeons] as a group should consider doing laser trabeculoplasty early in our treatment plans for patients who may be having difficulty affording their medications. It’s not our best pressure-lowering therapy but there’s no ongoing cost to the patient,” he says. However, he says, “It’s distressing that we have to turn to higher risk treatments just due to the economic effects.”

Switching to generics

“Our newer and most preferred glaucoma treatments in medication are quite costly at retail,” says Dr. Fechtner, so another option to help patients struggling with expenses is to revert to older medical treatments due to the relatively low cost.
There are some older medications, which are still good even if they may not offer all the advantages that the newer ones do, Dr. Fechtner says. In fact, he has started using more timolol in treating his patients with no pharmacy benefits. “Timolol half percent, once daily is quite effective in many patients,” Dr. Fechtner said, “For people with light- colored irises, .25%timolol may be all that’s needed.” As with all our patients, we need to take a complete medical history and rule out medical conditions that may be aggravated by timolol, he cautions
Timolol is one of those medications being offered by large pharmacies for $4 a month or $10 for a three-month supply, Dr. Fechtner explains. Also, Pilocarpine, though with a well-known side effect, is at an affordable $4 a month, he adds.
Switching to generics can also help patients who have pharmacy benefits as the cost of medications is usually based on a tiered system with generics being the least costly and branded medications being the most expensive or not at all covered.
For these patients, Dr. Fechtner asks them about their pharmacy benefits and their co-pays, and if they can afford their medications. “I’m considering the compromise of using generics where patients cannot afford the branded medications but have coverage for the generics,” he says.
The importance of discussing health coverage with patients cannot be overstated especially for patients approaching the Medicare Part D “doughnut hole.” For them, Medicare covers up to $2,700 in yearly prescription costs after which, the coverage stops and the patients have to pay out-of-pocket until costs exceed $6100 before coverage kicks back in. 
Dr. Fechtner says some of these patients may actually have generic coverage when they reach the gap and physicians can then switch back to the branded medications once full coverage returns.
Dr. Rhee says, however, that often, patients just remain on the generics: “Once we cross that bridge, usually we don’t come back. [The patients] stick to the generics.” Unless, of course, the drugs prove ineffective, then Dr. Rhee looks at different strategies.
While cost matters, Dr. Fechtner warns that ophthalmic generics can vary from the branded drug. “Let’s take the generic timolol 0.5%, 99.5% of what’s in the bottle is not timolol and by law it does not need to be identical to what was in the branded bottle. For generic latanaprost, 99.95% of what’s in the bottle is not latanaprost and that may result in differences in efficacy or tolerability,” he says.
Dr. Fechtner continues, “I don’t want to condemn generics but the generic ophthalmic medications do not go through the rigorous testing of the branded equivalents. And there have been instances in ophthalmology where generic eye drops have had unique problems not seen with the branded medications.”
Dr. Fechtner warns ophthalmologists to be vigilant when patients are switched to a generic and reassess the patient to make sure the drug is effective and tolerated.

Assistance from pharmaceutical companies

Apart from the above options, Dr. Fechtner also points out that many pharmaceutical companies have been generous in establishing assistance plans for people who cannot afford their medication and for the major glaucoma medications there are pharmaceutical companies that provide that medication at no cost for patients who qualify (see sidebar for details).

Editors’ note: Dr. Rhee has no financial interests related to his comments. Dr. Fechtner has financial interests with Alcon (Fort Worth, Texas), Allergan (Irvine Calif.), and Carl Zeiss Meditec (Jena, Germany/Dublin, Calif.).

Contact information

Fechtner: 973-972-2030, fechtnrd@umdnj.edu
Rhee: 617-573-3670, DougRhee@aol.com