As the medications for rheumatology become more expensive, the need for patient financial assistance becomes paramount. Unfortunately, commercially insured patients are finding it difficult to afford the exorbitant copays required by their plans, and the latest strategy of pharmacy benefit managers (PBMs) threatens to derail rheumatologic treatment goals. High deductible plans combined with copay accumulator programs spell disaster for the patient who has escalated to high dollar regimens.
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Explore This IssueFebruary 2020
What is this novel financial blow to rheumatology treatments? Copay accumulator is the most common name given to a novel concept created to increase patient responsibility for high dollar medications.
Just a few years ago, a patient with a high deductible insurance plan could use a manufacturer’s copay card to lower the financial impact of their expensive, brand-name medication. Once the medication was available as a generic entity, the medication was more affordable without the assistance of the manufacturer coupon. Either the deductible was met using the copay card, or the prescription benefits were separate from medical benefits and didn’t affect the deductible at all. With the copay accumulator program, any copay paid by a manufacturer coupon card will never count toward the patient’s deductible. Because the manufacturer assistance programs financial contributions are finite, the patient depletes all the manufacturer can offer, but still has the insurance plan’s deductible to meet.
Example: A patient has insurance with a $6,000 deductible and is taking several medications for his rheumatoid arthritis (RA). One of his conventional disease-modifying anti-rheumatic drugs (cDMARDs) costs $200 per month and the other costs $50 per month. His third medication is a biologic DMARD (bDMARD) that costs $5,000 per month, but the manufacturer offers a copay card that has an annual maximum of $15,000. Month 1, he must pay $250 for his cDMARDs, but $0 for his bDMARD. The same applies for Months 2 and 3. He tries to fill his RA medications in Month 4, and his pharmacy informs him that he owes $5,250 for his three medications. By this time he is feeling like his RA is under control for the first time in a year, but he just doesn’t have that kind of money. The $250 each month was bad enough. He calls his rheumatologist demanding a cheaper medication regimen. A different cDMARD may bring his copay down a bit, and starting a new bDMARD would allow the use of a new copay card, but in three or four months, he would be right back in the office with a high pharmacy charge requesting another change. By this time his deductible might be down to $4,000, but most working families don’t have that kind of cash on hand.
Insurers claim that the use of manufacturer-supported copay assistance is encouraging the use of high dollar medications before, or instead of, using conventional and less expensive regimens. As anyone who has tried to get a prior authorization (PA) lately knows, this is a spurious claim.
Every commercial insurer requires some form of step therapy, demanding the use of less expensive cDMARDs before approving coverage of a high dollar medication, such as a bDMARD or targeted synthetic DMARD (tsDMARD). Each insurer has a formulary that a rheumatology office must be cognizant of when prescribing a new regimen. Some insurers refuse authorization of a particular medication at all; others will authorize coverage, but don’t allow the use of a copay card for medications not on their preferred list.
How does a medication get chosen for an insurer’s formulary or preferred medication list? Simply stated, rebates.
Manufacturers pay rebates to the insurer’s PBM just for the privilege of being on the formulary. Every time a prescription is processed for a formulary medication, the PBM or insurer gets a rebate. How much currency is passed in this rebate? Is it $50 or $2,000? The amount of the rebate is unknown, but it is known that the rebate does not generally go to the patient or the rheumatologist.
Knowing this, who is really the party influenced by the manufacturer benefits? Because the rheumatologist doesn’t receive a rebate from the insurance company or the manufacturer for prescribing a particular regimen and the patient doesn’t get a rebate for using a formulary medication, it must be the organization making the formulary.
The Copay Maximizer
An alternative package offered to insurers by PBMs is a copay-driven program called a copay maximizer program. In this case, the maximum amount allowed on the copay assistance is divided by the number of times per year the prescription is dispensed, and that number becomes the copay each month. Taking our previous patient, the $15,000 is divided by 12 and the patient’s copay becomes $1,250 per month. The manufacturer will cover that $1,250 with the copay assistance card, and the patient will end up with a $0 charge per month for his bDMARD.
Remember, the manufacturer must still pay a rebate to the insurer, but the patient can continue to use a copay card for the large co-insurance without paying out of pocket for the medication. The copay maximizer generally does not allow the medication copays to count toward the patient’s deductible or out-of-pocket expenses, so the patient will still have cost-sharing responsibility for other healthcare needs.
Back in the Office
How can a rheumatology office handle these situations proactively? First, it is effective for someone in the clinic to encourage and assist patients in enrolling in the manufacturer support programs available for bDMARDs and tsDMARDs.
Second, patient education is essential. Encourage patients to call their health plan and ask if there is a copay accumulator in place. This information is not given freely to prescribers, but must be available to patients. Suggest that your patient read their invoices from the specialty pharmacy and look at what their insurance is paying and what the copay card is paying. If the copay card is covering more than $2,000 for two months in a row, the chances of exhausting the copay card’s annual benefit needs to be investigated.
Third, ensure that at least one clinic staff member has a working knowledge of the local commercial insurance carriers, what medications are preferred and which employers use copay accumulator programs.
Fourth, investigate options when a patient unknowingly exhausts the copay card benefits. Sometimes, patient assistance foundations can step in. Sometimes, the copay benefit can be extended. And sometimes, a manufacturer support program can assist.
Fifth, advocate for rheumatology patients and encourage patients to advocate for themselves. Providers can participate by using the advocacy resources available on the ACR/ARP website and contacting elected officials about this and other specific issues. Patients can participate by reaching out to their employer’s human resources department or contacting their state’s Department of Insurance or the National Association of Insurance Commissioners.
As new and specialized medications become more costly, insurers will demand patients share financial responsibility. Expect programs like copay accumulators and copay maximizers to affect more patients and make managing rheumatologic diseases more difficult. Knowing the playing field is key.
Wendy Ramey, BSPharm, RPh, CSP, is a clinic-based specialty pharmacist at the University of Kentucky, Lexington, in the rheumatology program. She received her Specialty Pharmacist Certification in October 2016.
Author’s Personal Statement
I have a special interest in rheumatoid arthritis due to my own diagnosed RA in 2013. I feel a calling to help other patients find treatment regimens that will improve their quality of life by controlling the symptoms and side effects of their autoimmune diseases.