The Rationale
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.
The Reality
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.
