Pharmacist with bottle of pills

Specialty Medication and the Patient Copay Offer

As you likely know, a “specialty” medication is a drug that treats rare and/or complex diseases and disorders. There are many complexities and challenges associated with getting patients on a specialty medication and keeping them on therapy.

Typically, a patient will need a prior authorization, step therapy or some other type of authorization, and will be required to go through a specialty pharmacy to get their prescription filled (most are mail order type pharmacies). Every PBM has a different list that they define as “Specialty”. It depends on which PBM the patient is signed up with, and what that PBM considers specialty or 4th tier. In some cases, there are six tier PBM lists, which adds even more complexity.

Costs & the Logistics lifecycle

Cost is a key consideration for patients who have been prescribed specialty medications. Fortunately, the manufacturers and distributors have an arsenal of assistance programs at their disposal to help patients, but the many forms of assistance can be confusing for patients.

Often, patients don’t initially know who will cover their medication, what pharmacy to go to and what assistance programs are available. And with the HUB services for specialty pharma expanding, and an increasing number of criteria to be a candidate to receive the drug, it makes it that much more difficult for an already stressed patient to comprehend all the details. However, once the patient is in contact with their HUB, they will find that the HUB makes the process easier for them. If a manufacturer copay offer is embedded in their process, the patient is much more likely to be aware of the program and therefore take advantage of it.

Patient adherence is heavily influenced by cost, accessibility and side effects. Many specialty drugs have side effects that are serious enough that they must be monitored. Patients may discontinue therapy and move to another “equivalent drug” option as a result of any of the above factors. This may be looked at by the brand as a discontinued therapy or reported as an adherence drop. However, this is not a true patient adherence drop; rather it is simply a discontinuation and thus an adherence drop for that particular medication.

True therapy abandonment and switching activity is very hard to measure when it comes to a specialty drug’s patient copay offer as patients discontinue for reasons other than price at a much higher rate than retail medications. More serious side effects drive more discontinuations. All these key factors must be considered when constructing your brand’s copay program.

Accumulator Influence on Patient Copay Programs

Currently accumulator programs only impact a small percentage of specialty pharma sales, however they create such a negative impact on the patients in those programs that they must be monitored.

Accumulator programs kick in when a manufacturer coupon is involved. In those cases, the PBM will separate the funds the patient has spent, and although they take money from the manufacturer on behalf of the patient via the copay program, they will not apply those payments towards the deductible.

The result is that the funding for the copay program runs out once the annual program cap is hit and the patient is then left with a much higher OOP expense. Patients who may be accustomed to paying $10 for their prescription for the first 6 fills may suddenly be looking at a bill for $3000+. This creates a very high risk that the patient will abandon that brand looking for another brand with copay assistance, or even worse…the patient will abandon therapy altogether. Non-adherence is very troubling since we know non-adherence to these specialty drugs causes mortality rates to increase.

The Bottom line

We all know Specialty Pharma products are expensive, but the complex combination of price, logistics, and the potential serious side effects of these drugs makes obtaining them and staying adherent difficult for so many patients. The patient copay programs put in place by the manufacturers certainly help but knowing what the right program is for each brand is a science not a guess.

There are many opportunities to structure solid programs to determine the best offer for the patient, while maintaining brand equity and ensuring the bottom line meets brand goals.

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