- Anticipating and responding to changes in health plan benefit structures payment practices
- Meeting the needs of the patient without being a target for health plans.
- Exceeding expectations for patient access in clinically competitive markets
Health plans are adopting new benefit structures and payment practices
that have a profound financial impact on patients and the sponsors of patient affordability programs. Too many times, the impact of these circumstances are not understood soon enough, and medication access and adherence are put at risk.
One such matter impacting patients is the manner in which cost-sharing expense is now assigned to covered services. Traditionally, health plans arbitrarily split health plan level cost-sharing expense between medical and pharmacy benefits; the split was frequently about 80%/20%, respectively. More recently, health plans have implemented “coordinated accumulators” that allow health plan level cost-sharing expense to be assigned to any claim that is processed, medical or pharmacy. As such, a pharmacy benefit drug that was previously exposed to only 20% of a health plan’s annual maximum out-of-pocket expense can now be exposed to most or all of the health plan level cost sharing expense.
The coordination of cost-sharing expense between medical and pharmacy benefit plans is increasingly common. Large increases in pharmacy benefit cost-sharing expense have often occurred for patients who have very limited medical benefit expense but use an expensive pharmacy benefit drug. Patients who are frequently affected include patients using drugs like growth hormone or self-administered DMARD’s and who may only see their prescriber for quarterly assessments. Some program sponsors have incorrectly assumed their drugs were being impacted by “accumulator adjustment programs” or similar, when the real culprit was “coordinated accumulators”.
Another benefit design impacting cost-sharing programs is the “buy-up” copay, frequently used for retail (vs. specialty) drugs. This copay amount is determined differently from typical methods of assigning patient cost-sharing expense. A buy-up copay is typically assigned to a brand drug with generic competition. For example, a health plan may contribute $20 toward the $25 pharmacy cost for a generic drug with a $5 copay. The brand drug may have a pharmacy cost of $300. The brand drug may be covered, but the “buy-up” copay is $280; this is computed as the pharmacy cost for the brand drug less a plan contribution of $20 for the generic drug. In this manner, the brand drug is often ”covered” without utilization management (PA, step-therapy, etc.) because the plan is financially indifferent to which drug the patient may use. Health plans that use this type of copay may offer coverage of a brand drug without any utilization management controls; however, this type of coverage is unfortunately not a “win” for the brand.
“DIR” fees imposed on pharmacies by PBM’s are a complex matter; just understand that these fees allow a health plan to penalize a pharmacy for certain practices (such as dispensing non-formulary drugs). DIR fees are typically assessed against a pharmacy on a quarterly basis. What this means is that successful coverage appeals and other brand “wins” may not tell the full story. Pharmacies may be reluctant to dispense drugs that increase DIR fees, regardless of coverage determination.
The key take-away here is that coverage and plan permission status is not the full story when it comes to patient access. Also, copayment assistance programs can see significant increases in program utilization due to benefit designs that have nothing to do with “accumulator adjustment” programs, or similar. Benefit design and payment practices are increasingly important over and above coverage and permission requirements. The sponsors of copayment assistance programs are well advised to seek advice on how the roll out of new benefits and payment practices may impact brand access strategy.
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