Benefit Plans Can Influence Specialty Patients to Switch to Less Costly Alternatives


As the popularity of copay cards for expensive specialty medications increases, health plans are devising new ways to steer patients into using more cost-effective options.

As the popularity of copay cards for expensive specialty medications increases, health plans are devising new ways to steer patients into using more cost-effective options.

There may only be one certainty surrounding the use of copay cards for specialty medications: no one, especially payers and pharmacy benefit managers (PBMs), knows how to incorporate them successfully into business strategies.

This became abundantly clear during the 2013 Academy of Managed Care Pharmacy (AMCP) Nexus meeting held October 15 to 18 in San Antonio, Texas. While it was not explicitly stated, audience participation questions during a panel called “Specialty Pharmacy Insights: What Are Managed Care Plans Doing?” seemed to imply what payers and PBMs think of copay cards: 2 of the proposed answer choices coupled with the question, “How do you view non—needs-based copay coupon cards?” included “A mechanism to promote brand loyalty” and “A mechanism to circumvent benefit designs.”

Historically, payers and PBMs have disliked copay cards. In their view, coupon programs unnecessarily promote the use of higher-cost medications over lower-cost alternatives and have the potential to undermine member financial incentives associated with cost-sharing differentials. In addition, many payers argue that federal programs such as Medicare and Medicaid prohibit the use of copay programs due to federal anti-kickback laws. (It is unclear whether the new health insurance exchanges also qualify as subsidized government programs, meaning that insurance purchased on them could also prohibit the use of copay cards.)

Lida Etemad, PharmD, MS, vice president of pharmacy management strategies at UnitedHealthcare, presented her company’s approach to handling copay cards for specialty medications during the aforementioned AMCP session. Starting January 1, 2013, she explained, UnitedHealthcare blocked use of copay cards for 6 specialty medications that it had deemed nonpreferred specialty products. The company implemented this policy by working closely with its specialty pharmacy, OptumRx, to train employees and inform plan members about the change through a “high-touch” member campaign.

Prior to the start of the exclusion campaign, UnitedHealthcare used a number of strategies to communicate the new policy to covered patients and physicians in its network. These included:

  • Letters sent to prescribing physicians 60 days prior to program rollout
  • Letters sent to members notifying them of the copay exclusions 45 days prior to rollout
  • Specialized customer service agents to handle calls from patients who were prescribed the 6 excluded medications
  • Offer of a pharmacist consult to these patients
  • Offer of OptumRx outreach to prescribers to obtain a new prescription for a lower-cost alternative

In essence, patients were given the option of moving to a lower-cost alternative, or continuing to take the excluded drug and pay the full cost share.

Dr. Etemad noted that a claims analysis campaign of UnitedHealthcare patients indicated that 43% of members were interested in learning more about lower-cost alternatives to their prescribed therapies, and 23% of members who contacted their doctor on their own switched to a lower-cost alternative.

Patients with higher baseline costs had higher switch rates, as did patients who were taking a greater number of baseline medications. Surprisingly, as Dr. Etemad noted in her presentation slides, the presence of a deductible did not seem to matter—even a higher-cost deductible did not provide sufficient motivation for patients to switch to a lower-cost alternative. However, the “rate of switch was proportional to underlying benefit design,” which Etemad said explains the “vast majority of behavior” in terms of therapy switch rates.

The program produced a nearly 13% relative decrease in Humira market share, as there was a large shift toward Step 1 products instead. It also led to a 34% relative decrease in the use of CellCept, along with increased use of the generic equivalent. Use of Gilenya, however, did not decrease. Although efficacy measures were not discussed in the campaign, Dr. Etemad said that “subgroup analysis is ongoing to determine if patterns exist” to explain the lack of decrease in Gilenya use.

The UnitedHealthcare researchers also looked at the effect of excluding the 6 specialty drugs from coverage on drug discontinuation rates. They found that 20% of Humira users did not fill a prescription for Humira or an alternative through March 15, 2013. According to Dr. Etemad, this may not be a direct result of the program, as “similar rates of discontinuation were seen for those impacted and not impacted by the program.”

In conclusion, Dr. Etemad said that UnitedHealthcare’s program appeared to have a direct impact on rate of switch and that limiting facilitation of copay cards led to significant cost-savings for the health plan. Based on the program’s success, Etemad explained, the payer plans to expand the program to 25 more specialty drugs by January 1, 2014. These include:

  • Genotropin (somatropin [rDNA origin])
  • Norditropin Flexpro (somatropin [rDNA origin] injection)
  • Tyzeka (telbivudine)
  • RibaPak (ribavirin)
  • Aubagio (teriflunomide)
  • Rebif (interferon beta-1a)
  • Neulasta (pegfilgrastim)‎
  • Adcirca (tadalafil)
  • Revatio (sildenafil)
  • Kineret (anakinra)
  • Myfortic (mycophenolate sodium)
  • Neoral (cyclosporine)
  • Prograf (tacrolimus)

With the exclusion of Aubagio (and earlier in the year, Gilenya), Tecfidera (dimethyl fumarate) would be the only FDA-approved oral therapy option for the treatment of multiple sclerosis that would still be covered by UnitedHealthcare. While Tecfidera is taken orally, it needs to be administered twice a day, unlike Aubagio and Gilenya, which only need to be administered once a day. Neulasta, which is also on the list of drugs to be excluded from coverage, is a long-acting pegylated filgrastim used as a supportive therapy to treat postchemotherapy neutropenia. Although Neupogen (filgrastim) is a cheaper alternative to Neulasta, it is not a long-acting agent. The other alternative to Neulasta, Granix (tbo-filgrastim), is not yet available for use in the United States. Although Granix has been approved by the FDA through a Biologics License Application, and is touted by some as the “first biosimilar” to come to market in the United States, this product may be associated with other difficulties in terms of accessibility. Even though Granix is approved, it cannot be marketed until November 2013 at the earliest per an agreement with Amgen.

It appears that eliminating specialty drugs that are high-priced, oral options is a strategy many PBMs and payers will embrace. Recently, Express Scripts released a list of specialty pharmacy formulary exclusions that included Xeljanz (tofacitinib), the only oral biologic for the treatment of rheumatoid arthritis. Although problems with patient adherence are known to increase overall member costs to a health plan, neither Express Scripts nor UnitedHealthcare stated whether current adherence rates to specialty medications influenced their decisions to exclude or include certain medications.

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