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How Well Is Your Copay Program Performing?

Wednesday, June 21, 2023

On the surface, copay programs may appear to be operating well, with a good balance of affordability for both the patient and the manufacturer. However, when you dig beneath the surface and look beyond the averages and monthly trends provided by most copay program vendors, there are often business and market insights that, if interpreted correctly, can provide significant opportunities for program optimization.

With changes in insurance coverage occurring rapidly, ensuring patient affordability while understanding payer dynamics and policy changes in real-time are critical to managing copay program costs for a pharmaceutical manufacturer. For example, by looking at a copay program report, there may be no reportable change in the percentage of patients insured and covered for the manufacturer’s product and little change in the average copays by payer. However, these metrics may mask what is occurring below the surface and many manufacturers miss important shifts such as a higher number of patients moving to high-deductible plans or products shifting to higher copay tiers. This cohort of high-cost patients must be tracked over time to determine if they are:

  • In high-deductible plans, and if so,
  • Do they eventually meet their deductibles to get lower copays; or
  • Are these patients in plans with accumulators or maximizers;
  • Are these patients in plans with tier 3 or higher copays where they never become more affordable to the manufacturers

These findings are critical to determining business rule changes that may be implemented to improve program functionality and mitigate increasing costs. The ongoing management of those commercially insured patients rejected by the patient’s primary payer (i.e., the Insured NOT Covered patient group) is almost always a balancing act for the manufacturer between providing patient support and mitigating the program expense of these patients. Breaking these patients down into cohorts based on the non-coverage reason and tracking them to determine what percent of this patient group ultimately gets coverage and in what timeframe is essential to setting business rules for this patient group. This data can also be used to identify plans where the product is being managed as part of an Alternate Funding Plans (AFPs) or Specialty Pharmacy Carve Out Plans.

Before adjusting your business rules, it is essential to model the impact of the copay card offer or changes in business rules to determine the appropriate balance between product abandonment versus changes in overall benefit expense. This enables the manufacturer to make informed decisions in an increasingly competitive environment.

Another factor in the ongoing maintenance of a successful copay program is the management of the participating pharmacies. Copay vendors should monitor pharmacy behavior over time to determine outliers in performance standards. Creating pharmacy scorecards that highlight behavior against critical program metrics and financial performance is key. Pharmacies that appear as outliers can be quickly identified and decisions can be made regarding the need for additional training or potential termination of that pharmacy in the program. Additionally, pharmacy monitoring can provide information on potential offer changes that need to be put in place to mitigate the risk of misuse.

These examples provide just a few of the areas within a copay program where analytics and monitoring copay program performance can uncover unnecessary program expense and misuse of the program, as well as identify opportunities to enhance the overall experience for the participating patients, HCPs, and pharmacies.

UBC is focused on using experience and data-driven insights to refine and optimize copay benefit programs across large, mid-size, and emerging pharmaceutical and biotechnology companies. To review your affordability program, download our complimentary checklist here. To discuss how our copay and affordability experts can help your brand, click here.

About the Author

Lori Schwartz, Executive Director of Analytics, has over 35 years of experience in patient longitudinal data analytics and modeling. In her role with UBC, Lori provides our affordability clients with unique and detailed program insights and recommendations that allow them to feel confident in taking the necessary steps to optimize their copay card offers and affordability strategies throughout the product lifecycle.