Are You Covered Healthcare Insurance Protection Concept

Adapting your Program for Insured Not Covered (INC) Patients

Many copay programs have an INC offer component but many of our clients don’t differentiate the two types of patients typically grouped within their program and this can cost them. INC can be two types of patients:

Insured Not Covered 1 (INC1) – have commercial coverage but are also in a high deductible health plan so they don’t technically have coverage now, but could be covered in the near future.

Insured Not Covered 2 (INC2) – have commercial coverage but their plan does not have your drug on formulary so they have no coverage. In this case you should consider them not covered. 

Non covered patient (NC) – don’t have commercial insurance at all and may never have coverage so they are technically a cash paying patient.

A true INC1 patient will have to pay full price for your medication while they are in their “not covered” status because they first need to meet their program deductible or your medication is currently not covered under their plan.  They will most likely receive coverage in the near future, substantially reducing their out-of-pocket expenses and taking less from your copay program budget.

If you are managing an acute brand, the “waiting period” for these patients to secure coverage may be too long, as by the time they secure it, their therapy is complete. But for chronic brands, it is very important that you treat the INC1 patients differently because in a few months their insurance plan will kick in funding and your cost for including them in the copay program will be greatly reduced.  Here, it may be worth your while to reduce the patients’ out of pocket burden to get them through their HDHP deductible as they may very well become adherent patients long term.

This is not the same scenario for the INC2 and NC “cash patients” who have no coverage. In these cases, the outlook even for chronic brands isn’t as rosy, because these patients will most likely never be covered and always have to pay full retail, and subsidizing that financial burden can be too much for a brand to handle. You can still set up a copay offer for the cash patient but you must make sure to watch your margins so you don’t lose money here.

For the “INC1” patients, many chronic brands can actually lose money getting the patients through their high deductible periods, but the strategy is to recover some of those losses as patients continue their therapy longer-term. Unfortunately, this strategy does not hold up for the acute brands which is one of the reasons that patients will not see deep discounts on those brands where the patient therapy is three months or less.

The key to putting together offers for both the NC (cash) and INC2 patients is to make sure you are accounting for all costs in your calculations including any applicable managed care contracting costs, cost of goods etc., so you don’t unknowingly lose money ongoing.

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