Explore the issues with changes to manufacturer assistance programs and potential solutions
Are you aware of the changes to patient assistance programs by several different pharmaceutical manufacturers? AbbVie Inc, Janssen Global Services, Vertex, and Pfizer are just some of the manufacturers who modified their program eligibility for 2023. These modifications are in response to health plans and pharmacy benefit managers who are exploiting these programs via copay maximizers, accumulators and specialty carve outs to control their internal costs.
Several of the programs have modified their copay assistance structure to exclude patients with commercial health plans that use a “copay maximizer”.
What are copay maximizers?
A copay maximizer is a program in which insurance plans or Pharmacy Benefit Managers (PBMs) set out-of-pocket costs equal to the maximum annual value of a manufacturer’s copay program. Ultimately, this reduces an insurance company’s or PBM’s costs by shifting more expense onto manufacturers. While manufacturers have historically offered generous copay programs, it was uncommon for most patients to use the full amount because their annual out-of-pocket responsibility was lower than that of the manufacturer copay program. Research suggests that 73% of commercial market patients belong to plans that have implemented a copay maximizer program. The additional money extracted from manufacturer copay programs is draining funds originally intended for patients.
How will this market change affect patients?
First, patients who had and depended on financial assistance for lifesaving, high-cost drugs may no longer qualify for these manufacturer programs. A recent Wall Street Journal article shared several examples of how this directly affects commercially insured patients.
Second, we have to ask the question: have insurance plans and PBMs with copay maximizers adjusted their benefit design to avoid excessive patient responsibility on the impacted medications? If not, patients will have extraordinarily high out-of-pocket responsibilities. This is troubling because reports show that prescription abandonment rates are 45% when the out-of-pocket cost is over $125 and even jump to 60% when drug costs rise to more than $500. However, when a prescription carries no out-of-pocket cost, abandonment rates are less than 5%.
Third, it’s possible the funds these manufacturers were using for copay assistance could be reallocated to non-profit foundations and charitable programs who provide philanthropic aid to patients.
Lastly, if the statement above ends up proving true, we may see other manufacturers follow suit as a strategy to push back on copay maximizer programs and leverage alternative methods to support access and affordability for their medications.
What measures should you take?
First, invest in a solid patient assistance strategy. There are thousands of programs that offer philanthropic aid for patients who cannot afford their medication. Many of these are diagnosis-based assistance foundations which can be challenging to navigate if done manually.
Second, invest in technology to manage the patient assistance process for patients. The drugs impacted by these manufacturer changes are expensive and commonly used, so the likelihood of patients struggling with access or affordability is significant. Leveraging technology to automatically match patients to programs and digitally enroll them to secure necessary funds is valuable and will improve overall health.
Lastly, the future of patient assistance will always be dynamic. Specialty carve-out strategies, copay accumulators and copay maximizers continue to evolve and disrupt the market. However, having the ability to secure alternative funding for your patients during market fluctuations is critical in today’s economic environment and for sustainability in the future.