At CBI’s ninth annual Coupon & Copay Forum in October, industry experts gathered both in-person and virtually with an audience of pharma leaders and service providers charged with patient access. With 79 companies represented, and over 70% attending from life sciences companies, the conference had a strong cross-section of participation including brand management, market access, reimbursement, patient support, and trade.

In parallel with the growing complexity of specialty medications, the patient journey has also become more complex, and access solution providers need to get creative about simplifying this experience. Technology solutions are clearly important, but the answer lies not in adding dizzying layers of ever-more tech, it’s in stripping those layers down to the essence of what patients will actually use.

Meanwhile, the insurance industry, the payer world, pharma market access strategies, and patient cost sharing realities have also become more complex, so copay and coupon programming has needed to evolve in its sophistication in order to keep pace and stay ahead of patient and HCP needs.

As conference chair, I noticed four key themes that emerged from the conference:

1. Copay Utilization Continues to Increase Amid Pandemic

Last year, patients’ out-of-pocket exposure on prescription drugs totaled approximately $91 billion, with copay coupons offsetting $14 billion of that for a total net exposure of $77 billion.

These coupons are critically important to patient care. In a September survey of more than 1,000 healthcare professionals in the Physicians’ Desk Reference network, which is now part of ConnectiveRx, more than 70% either “agreed” or “strongly agreed” that copay coupons encourage patients to stay on their medications. A similar percentage agreed that copay programs help them prescribe when managed care is restrictive.

The use of coupons has helped to keep patients’ actual costs for their medications under control, even as average copays have risen dramatically. The average copay cost per claim faced by a patient in January 2021 was 20% higher than in January 2020. That translates into an average copay of about $327 in 2021 versus $88 in January 2013. But copay programs kept the actual out-of-pocket cost to the patient for those branded medications almost unchanged—helping keep them on therapy.

2. Accumulator Programs are Still an Issue

Approximately 80% of commercially insured beneficiaries are on plans where one of these strategies “could be” put in place.

The new CMS rule on patient affordability programs and their connection to increasing anti-accumulator rulings was also a key topic of discussion. Possible solutions for manufacturers could include lowering the offer amount to patients to avoid best price impact, have patients pay out of pocket then submit a rebate claim, or work with pharmacy benefit managers (PBMs) to ensure all are compliant with the new rule.

3. Digital Access and Tech-Enabled Adherence is a Game Changer

Digital access to coupons and other savings tools have been a game changer. The patient user experience is streamlined because now they can access coupons from their text messages, rather than having to print out and bring the document to the pharmacy. This process allows for much easier compliance around auditing and monitoring requirements for brands. Plus, tracking this data can ensure optimal savings offers can be updated quickly behind the scenes without worrying about outdated printed coupons confusing patients.

On the mobile front, app fatigue is real, with more and more of us maxed out on our smartphones and all of its apps. The average person has 80 apps but only uses nine on a daily basis. Text messages have become increasingly popular as an effective way to reach patients, but they do have limits. They are not secure and the communication—“yes,” “no,” “help,” “stop”—is currently less than engaging.

And while call centers won’t be replaced by tech, new tech adds to the patient experience and makes it easier and more efficient for agents. Virtual assistants for patient support are a wave from the future. Chatbot skills are getting better every day, with robots guiding everything from uploading documents before an appointment to navigating with the banking industry and insurance companies, and the list goes on.

4. Specialty Patient Support Program Needs Remain a Hot Topic

When excluding COVID-19 vaccination activity, the volume of specialty brand prescriptions has surpassed that of non-specialty brands, accounting for 38% of $465 billion in total prescription revenues in 2020.  On the brand side, payers are particularly sensitive to drug pricing, and specialty drugs are driving most out-of-pocket costs. The sum of these issues makes the topic of specialty brands—and how to effectively manage their copay programs—an important ongoing discussion.

The one-size-fits-all approach never works with a specialty brand. Managed care coverage spans both pharmacy and medical benefits, distribution networks are complex, out-of-pocket costs are high, legislative changes are impacting copay programs and drug pricing, sites of care are shifting, adherence continues to be a challenge, and payer accumulator adjustment programs continue to be a threat to patient access. Given this scenario, innovation and a greater focus on the patient experience are increasingly important in the design of a copay assistance program.

It’s important that a program for a specialty drug can function in any managed care scenario, with no disruption in therapy when a patient’s coverage changes. This is especially critical during the launch phase, when payers are making coverage determinations. Closely tied to coverage type is the access channel. Complex distribution networks include specialty pharmacies, retail pharmacies, specialty distributors, and an increase in the number of in-office dispensing pharmacies. Sites of care are shifting away from the outpatient hospital setting for many infusion products to the home care setting.

Legislative changes cannot be overlooked when designing a copay assistance program. The implementation of payer accumulator adjustment programs has been upheld and pending legislation regarding best price reporting will have a significant impact on program design, if passed.

Innovative thinking is critical to the success of any copay program for specialty products. Assistance must be available under any managed care scenario, at any pharmacy, and at all possible sites of care. The programs must also be flexible to accommodate market dynamics, legislative changes, and advancements in technology. Vendors will look to trends in other industries, such as banking, to spur innovation. Copay assistance programs for specialty products will continue to evolve by keeping pace with trends across industries, market dynamics, and regulatory changes.

  • Chris Dowd

    Chris Dowd is Senior Vice President of Market Development at ConnectiveRx. In his more than 25-year career, he has become a recognized voice in the patient affordability and specialty medication arena, pioneering prominent copay and patient affordability programs, and creating innovative solutions for his clients.

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