Copay program strategies to handle High Deductible Health Plan (HDHP) influences

Written by Al Kenney on 17 September 2017. Posted in Co-Pay Program Optimization

HDHP Influences

With the number of HDHPs increasing every year, brands are searching for ways to best cope with the issue of uncovered patients with high OOP costs. Having great managed care coverage sounds great but brands know it’s not nearly what it once was as many of their patients could end up with a bill for the full retail cost of the drug unless they can utilize the brand’s copay program.

Looking for the best way to manage this situation, many brands are considering one of three different strategies to help cope:

1) Annual cap – no "cap per use" but rather one flexible overarching cap that will cover the entire cost of the first few scripts to get the patients through their high deductible.

2) Increased Q1 cap – Increasing the cap for the first 3 months of the year to help cover the patient's deductible when it is reset each January.

3) First 3 uses inflated cap – A higher cap for the first 3 uses regardless of when the patient starts their therapy.

Depending on your brand and its situation, not every one of these strategies will work.  Knowing which of these strategies will be effective will depend on whether your brand is for an acute or chronic condition, what comorbidities may be present, and the overall drug price.  For example, if your drug is for an acute condition with maybe an average of 2 uses and with patients coming in and out of the franchise throughout the year, then an increased Q1 cap would not be effective for your brand.

With only about 56% of the HDHP claims coming in Q1 each year, taking the strategy of increasing your Q1 cap could backfire on many brands. Annual caps can work well but their values need to be carefully composed or else the brand may wind up paying much more than is needed to keep your trial and adherence numbers in check.