Pharmacies are critical stakeholders as well as being a direct link to the patients the healthcare industry aims to serve. Pharmacists are trusted community members who support and guide patients in their time of need. Recent pressures on local and chain pharmacies have created new challenges in how pharmacies operate which poses a potential impact on manufacture-sponsored copay programs. It is important to recognize and plan for the conditions and pressures facing today’s pharmacists when seeking to optimize your copay program.
COVID-19 dealt a heavy blow to most industries across the world with lasting effects on the workforce that persist today. Pharmacies were doubly impacted by the pandemic, being asked to ramp up services to help more patients while losing valued employees directly, or indirectly, to the virus. A 2022 survey conducted by the American Pharmacists Association (APhA) on pharmacy workplace conditions across the US found that 78% of respondents experienced workplace exhaustion and 40% of respondents felt under-supported in their role.1 Many pharmacists decided to leave their jobs, citing stress and being overworked as the main reason. This led to a continued shortage of pharmacists supporting the growing need to help more patients. In October 2023, the Associated Press reported that “larger drugstore chains often operate stores with only one pharmacist on duty per shift” making it difficult for the reduced number of pharmacists.2 Pharmacies are now more understaffed and under-experienced than ever, which can lead to errors in claim processing that can be costly to patients and copay programs.
Partnering with Pharmacists
A plan for mitigating pharmacy claim errors includes education, oversight, and communication. The first step is to provide pharmacists with easy access to information on how to correctly process the copay card. For example, when a patient’s insurance does not cover a product, a less experienced or overworked pharmacist may opt to process a copay card in the easiest way possible, which is usually as a primary (cash) claim. This will yield a high-cost claim to the copay program, but also a high out-of-pocket cost to the patient. In attempts to guide pharmacists, many copay programs now offer detailed instructions on their cards explaining how to process claims for insured patients who do not have product coverage beyond the traditional COB split billing and Coverage Code. Some programs go as far as to outline system-specific steps for large chain pharmacy’s processing software. Other programs have developed and distributed separate digital and printed pharmacy instructional documents to help guide pharmacists through varying coverage scenarios. Arming pharmacists with information in hand allows them the best opportunity to apply copay cards correctly and seamlessly.
Monitoring copay claims by pharmacy is a lead indicator of where processing issues may exist. Access Managers need to keep a close eye on key metrics around patient coverage and initial copays by pharmacy so they can identify problem areas quickly. A pharmacy that makes a habit of processing copay claims as cash by default will quickly display an outlier against the national average, considering that over 64% of patients in the US had commercial insurance coverage in 2022.3 A pharmacy showing a high volume of claims for insured patients whose claims have been rejected by the primary payer due to PA requirements is an indicator the pharmacy may not be following up to initiate the PA process. Other identifiable issues can be driven by the pharmacy processing software. A high percentage of claims for insured patients who display as having product coverage but are being asked to pay nearly the full amount can be an indicator that the pharmacy system is automatically applying a discount card before the copay card. Copay business rules block known discount card programs from being used as primary insurance; however, some discount cards can go unrecognized due to shared payer BINs. Vigilance in this area will flush out any new or previously unidentified discount cards. Each of these indicators should be monitored closely. UBC’s patient access services include pharmacy scoring reports as a standard tool in our copay solution to assess pharmacy performance on an ongoing basis.
Given the specific case, scope, and circumstances, manufacturers can opt to have their field reimbursement managers or copay call center support teams reach out to pharmacies to provide further instruction and/or inquire about the copay processing habits. Program announcements and direct pharmacy contact help raise awareness and remind pharmacies of the copay eligibility requirements and processes. Many times, pharmacists are unaware of processing errors occurring at their pharmacy or of the unintended consequences when they are contacted. Information is typically well received, and pharmacy staff can be retrained to promote proper claims submissions. This open communication also reminds and encourages pharmacists to leverage the copay call center support services when questions arise.
There are many external pressures today increasing costs for pharmaceutical manufacturers, pharmacies, and patients alike. Collaboration and communication with our pharmacy partners to ensure copay programs are utilized as intended are low-hanging fruit in the ongoing struggle to provide cost-effective medications for patients. As pharmacies continue to try to staff up and train employees, there is an opportunity for manufacturers to inform and advise the next wave of pharmacy professionals, while ensuring best practices for their copay program.
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
Damian Quintana is a Director of Project Management at UBC. With over 20 years of experience in healthcare and a decade focused on patient access and support, he has designed, implemented, and managed hundreds of copay benefit programs for both large and emerging pharma. Damian collaborates closely with clients and third-party partners to create copay benefit programs that target strategic imperatives and track KPIs toward brand goals and an optimal patient experience.
- Pharmacy Times. “Survey Show Pharmacy Teams Continue to Be Stretched Thin During Pandemic” https://www.pharmacytimes.com/view/survey-shows-pharmacy-teams-continue-to-be-stretched-thin-during-pandemic. Accessed 11/1/2023.
- Associated Press. “Pharmacist shortages and heavy workloads challenge drugstores heading into their busy season” https://apnews.com/article/cvs-walgreens-pharmacists-drug-shortages-c7a94430a2c9d11779a684c2bcfc4c2c#. Accessed 11/7/2023.
- US Census. “Health Insurance Coverage in the United States: 2022” https://www.census.gov/library/publications/2023/demo/p60-281.html#:~:text=In%202022%2C%2092.1%20percent%20of,91.7%20percent%20or%20300.9%20million). Accessed 11/7/2023.