Optimize Your Copay Program’s Business Rules

Now more than ever, you’ll need to understand and pay more attention to the business rules in your copay program.

This is an essential step to ensure all your strategic thinking gets executed at the pharmacy exactly as you thought you had defined it. There are many examples where loosely built business rules cost brands millions more simply because the objectives were not understood thoroughly and the rules were subsequently not set up properly.  For example, incorrectly structured business rules might give the pharmacist the flexibility to run a commercial patient as a cash patient which over time could cost you millions.

One of the biggest oversights is how your program treats the ever-growing group of “insured but not covered patients” (INC). These may be patients just starting the year and paying towards their high program deductibles, or your drug may not be on the patient’s formulary plan yet.

There are technically at least two types of INC patients:  

  1. Those who have insurance but don’t have formulary coverage for your brand (so these are really cash payers who are “insured”),
  2. Those who have commercial insurance coverage for your brand but need to satisfy their plan deductible. These patients will eventually be covered for your brand, just not right now

INC – “A” patients will be thrown over into your cash payer bucket. This is why you need to pay special attention to your cash offer (or should think about having one). If you have no cash payer offer there will be a high likelihood, they will not fill due to having to pay your retail price point.

If you feel the majority of your INC patients are in type “B” and will be starting the calendar year paying out of pocket towards their deductibles and your offer is equal or more lucrative for your cash paying patients you should think about setting your business rules to specifically state that insured patients cannot be processed as cash payers, as if this is allowed it could cost you a bundle.

Depending on your brand’s specific situation, you may want to set up your business rules to specifically address these INC patients.  You should not only understand the possible number of INC patients presenting your offer at the pharmacy, but the potential impact of the two different types of INC patients and think about the way those patients will be treated in the delivery and execution of your offer.

You may not have a good handle on the percentage breakdown of these two INC patient groups and this makes it hard to plan out your strategy. Make an educated guess to get the process started. These programs have many business rule configurations and glossing over any of them could cost you big!

If you slack even a little bit and don’t think through the rules you implement, you may leave the door open for the pharmacist to send through incorrect or fraudulent claims and this could have a devastating impact on your bottom line. Just remember to spend the extra time to correctly configure your program’s business rules. You’ll be glad you did.

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