Reprinted from DRUG BENEFIT NEWS, biweekly news, proven cost management strategies and unique data for health plans, PBMs, pharma companies and employers.
By Lauren Flynn Kelly, Editor
December 7, 2012 Volume 13 Issue 23
UnitedHealth Group’s UnitedHealthcare unit will soon implement a novel initiative aimed at limiting the use of manufacturer-offered copay coupons through its specialty pharmacy network, while Blue Cross & Blue Shield of Rhode Island reportedly attempted a similar strategy but was forced to loosen its restrictions due to patient pushback. Such moves indicate a growing trend in the ongoing battle against copay offset programs, as several other companies say they are considering ways to target the use of specialty drug coupons as early as 2013, but are still grappling with some of the logistics.
Starting Jan. 1, UnitedHealthcare is targeting copay assistance cards to discourage members from using non-preferred specialty drugs in cases where there is a lower-tier agent on its preferred drug list. How are they doing this? The insurer’s network specialty pharmacies will no longer accept coupon cards when a member calls to fill a prescription for one of six drugs: Extavia (interferon beta-1b) and Gilenya (fingolimod) for multiple sclerosis, CellCept (mycophenolate mofetil) for patients receiving transplants, Humira (adalimumab) for rheumatoid arthritis, and Victrelis (boceprevir) and Peg-Intron (peginterferon alfa-2b) for hepatitis C. The action does not impact needs-based assistance programs.
The six drugs were chosen because of the “availability of therapeutically equivalent options that would provide patients a more affordable option,” United spokesperson Daryl Richard tells DBN’s sister publication Specialty Pharmacy News. The elimination of these coupons is estimated to impact less than 0.1% of members currently taking one of these drugs, he adds. An analysis of United’s pharmacy claims shows that 75% of members on a Tier 3 drug are using a copay coupon, and 45% of members take a Tier 3 specialty drug even when a Tier 1 or Tier 2 option is available.
Meanwhile, Navitus Health Solutions, LLC, tells DBN it is at the point of making a decision in the coming weeks on whether to start disallowing certain copay cards through its specialty pharmacy network. The Wisconsin-based PBM has already had conversations with its specialty pharmacy vendors, which expressed that they’d be willing and able to block the use of the cards on select medications if the PBM instructed them to do so.
“We as a company believe that copay cards have a potential benefit and also a detriment, so there’s kind of a double-edged sword when it comes to these cards,” says Brett Kelly, senior director of industry relations. On the plus side, when the card is used on a preferred agent, the member pays less for access to their drugs and is thus more likely to take them, he explains.
“The negative aspect is when they’re for non-preferred agents, what it does is it typically lowers the cost for the member but the health plan typically pays more,” he continues. “And that’s not always the case, but in most instances we have a reason or a rationale for why we decided to make these agents preferred and non-preferred and we have the clinically appropriate, lower-net-cost products in preferred tiers. So what it does in our minds is undermines the use of our preferred agents, and in the end leads to higher costs for our health plans and employer groups.” As a result, Navitus’s program would target only certain non-preferred agents with cards that are actively being promoted.
Challenges Exist in Tackling Cards
One dilemma in designing such a program is differentiating between a widely available discount card and something that’s being used because of financial need. “If in fact it qualifies their use because of financial struggles, then we deem that a copay card associated with a needs-based copay assistance card. But some of these supposed needs-based assistance cards really don’t have strong stipulations on who can actually use those cards,” asserts Kelly. “There’s no enforcement mechanism for most of them.”
According to The Zitter Group, over two-thirds of biologics, which are generally free from significant generic competitive pressure, offer copay offset programs. And at least 19 drugs in orphan disease categories have discount programs in place, reports the business intelligence firm.
Navitus recently conducted its own survey of the coupon market and sent requests to the manufacturers of the PBM’s top 20 most utilized drugs, including both specialty and traditional, asking if they had copay cards currently in effect, when those promotions started, and whether they intend to continue offering the cards. Of those 20, it was determined that only two did not have a copay card in place. Kelly adds that Navitus has been implementing various strategies to address the coupons overall, not just in the specialty realm, and plans to release a white paper next spring on the issue.
Meanwhile, Aetna Inc. tells Specialty Pharmacy News that it is considering employing some kind of strategy targeting specialty drug coupons. “We do not have a current policy regarding copay assistance cards although we are evaluating a number of strategies to ensure that we balance the needs of our members and the often inappropriate usage of these programs,” says Robert Galle, head of Pharmacy Benefit Management.
And while WellPoint, Inc. has no concrete plans to disallow specialty drug coupons, the insurer tells DBN it does have some concerns about their use and has begun exploring potential solutions. “It’s not something that we do today but we do recognize our competitors are blocking select coupons with certain manufacturers,” states Laurie Amirpoor, vice president of pharmacy operations.
“Our big concern is that there are unintended consequences associated with specialty drug coupons. We understand that the financial impact is very great on these members, but at the same time they have adverse effects in that they drive members to a product that may not be appropriate first line or at the time that the member’s diagnosed.” Amirpoor adds that these concerns exist regardless of cost. “Some of these newer agents are just not intended to be used as a first line of therapy,” she stresses.
As a result, WellPoint has mentioned to its specialty vendors that it would like to start exploring ways to curb the coupons’ use. “We haven’t really gotten into the details because part of the challenge is that the specialty pharmacies are the ones that get the reimbursement back from the manufacturer for these coupons, so we have to understand and they have to be willing to share with us how exactly do they get these reimbursements for the coupons, and are they willing to give that up?” explains Amirpoor.
WellPoint’s PBM partner, Express Scripts Holding Co., says it supports the use of copay coupons in certain instances where “brand manufacturers will offer a coupon to increase access to an otherwise price-prohibitive medication,” but generally opposes the use of the coupons if they’re costing the payer more.
Specialty Drugmakers Have More to Lose
One major difference between a specialty drug coupon and a traditional copay card is that there’s a much bigger return on investment for makers of specialty drugs, suggests Kelly. “If the cost of therapy is $100 a month and you give them $15 off, it takes a while to really make up for that, but if the cost of the drug is $1,500 a month and it costs you only $15 or $20, it doesn’t really take very many copay cards to make the card program pay for itself,” he explains.
“When you look at the specialty copay cards versus the traditional copay coupons, it’s a little different because drugs like Lipitor and Solodyn [which have copay cards associated with them] have direct generic alternatives, but in specialty there isn’t going to be an exact generic alternative,” adds Amirpoor. “Then there’s more open-mindedness as long as they’re promoted correctly. But ultimately, this is going to impact the member if not now, later. These costs will eventually get pulled into the premium, so there are long-term effects of using these coupons and we will use other utilization management tools to try to control the use of these drugs.”
WellPoint already has step therapy edits in place for certain classes such as rheumatoid arthritis, where use of a preferred specialty agent — which typically falls on a plan’s third tier with a $40 or $45 copay or a coinsurance with a maximum dollar amount of $150 to $300 per prescription — would be required before stepping up to a non-preferred agent.
Navitus employs similar step edits on specialty drugs, and Kelly says those can be a fairly effective way to enforce formulary compliance. If the company finds that technique is sufficient to naturally deter use of the cards and that taking things a step further wouldn’t make much of a financial impact on its clients, then those would be two reasons why the company decides not to go through with disallowing the cards.
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