Copay Organizations and Specialty Pharmacies: Partnering to Help Patients in Need

Specialty Pharmacy TimesFebruary 2012
Volume 3
Issue 1

Copay organizations play an important role in helping patients obtain their medications and have become integral partner with specialty pharmacies as they work together to support different therapies.

Copay organizations play an important role in helping patients obtain their medications and have become integral partner with specialty pharmacies as they work together to support different therapies.

As specialty pharmacy spending continues to outpace that of traditional therapies, managed care organizations continue the trend of increasing the cost share to the patient. Specialty pharmacies see this increase in cost sharing as a barrier to therapy initiation and adherence. Coupled with the current economic downturn, this has hampered the ability of many patients to afford their medications. Many are in need of financial assistance to initiate or maintain therapies.

Copay organizations play an important role in helping patients in need obtain their medications. These charitable organizations rely on fundraising efforts to support their mission. While all have different qualification standards, most consider household income, geographic location, and diagnosis when qualifying patients for financial assistance.

Copay organizations have become integral partners with specialty pharmacies as they share common goals of quickly starting and keeping patients on prescribed therapies. These organizations support many different therapies. Due to the fundraising efforts involved in supporting these charities, the covered diagnosis and grant amounts can be dynamic. Managing these funding changes has become a priority for pharmacies. For example, many specialty pharmacies have financial assistance specialists within their reimbursement departments to help coordinate and assist patients in gaining access to charitable grants.


Many patients first encounter abnormally high medication copay amounts in the specialty pharmacy environment. Most patients are familiar with their normal brand or generic copay amounts listed on their insurance card. When specialty medications are subjected to tiered pricing, patients are often surprised at the amount—and cost becomes a barrier. Specialty pharmacies can immediately permeate this barrier by offering sound financial counseling, which often introduces patients to copay assistance for the first time. This introduction is a very important step in educating the patient about the organization and setting the patient’s expectations of the application process.

The goals of the patient, prescriber, and pharmacy all align in quickly starting patients on their prescribed therapy. The time that it takes to first fill a prescription—“time to fill”—is an important industry metric, and a confluence of factors affect this time. Since out-of-pocket cost has been introduced as a barrier to therapy initiation, organizations strive to decrease the time it takes to approve the patient, otherwise known as “time to approval.”

“Time to approval” is defined as the time between referral to the organization and the time funding approval determination is returned to the specialty pharmacies. Some organizations have invested heavily in infrastructure and technology to propagate the goal of efficient therapy initiation to benefit the patient. “Time to approval” varies widely between organizations. Some report their “time to approval” to be within the same business day, while others report a 2-week approval determination period.

Copay organizations foster network relationships with specialty pharmacies in an effort to decrease this time. Electronic data interchanges between organizations and pharmacies also have proved to positively affect approval time. To facilitate the process, the organizations allow patients, pharmacies, and providers access to portal views to monitor patient application status, funding balances, and dispenses.

The patient’s interactions with the organization can also be a factor in “time to approval.” As mentioned, the introduction of the organization to the patient by the specialty pharmacy is an extremely important part of the process. The patient must understand that the organization’s intent, purpose, and mission is to be an advocate for their needs, thus the patient benefits by becoming a stakeholder in the process.

In recognizing the need to enhance the enrollment process and create efficiences, these organizations haveadopted Web resources. In addition to Web enrollment by pharmacies, prescribers can enroll patients, and often, patients can self-enroll. Some organizations pre-qualify patients for funding during the initial online application process. This instant feedback often provides additional motivation for the patient to initiate therapy.

Efficient communication between the organization and the pharmacy is extremely important during enrollment to ensure that the pharmacy is kept abreast of the patient’s application status. The organizations often provide this communication through electronic data exchange. Any delay in this communication adversely affects “time to fill.”


Once therapy has been successfully initiated, the second goal that aligns stakeholders is keeping the patient on therapy. It is important for the specialty pharmacy to know the funding allotment and funding balance for the patient. The mechanisms differ by organization; some utilize NCPDP transactions, others allow pharmacy portal account access, while some require mail or phone correspondence. Whichever mechanism is chosen, it is imperative that the organization and pharmacy communicate funding balances to prevent unanticipated funding lapses.

While most specialty pharmacies administer their own compliance programs, organizations also administer complementing services. Some organizations request status updates for patients with no reported dispenses within an expected time frame. Funding is often limited and allocated per calendar year; therefore if a pharmacy reports that a patient is no longer on therapy, the organization may free the remaining balance to help other patients. Using this synergy, the pharmacy and the organizations ensure that patients are following therapy regimens and allow for limited resources to reach more patients in need.

Organizations also offer patients the ability to track their therapy through patient portals. Interactive calendars are provided for patients to schedule upcoming injections, doctor appointments, and other therapyrelated activities. Many organizations also offer surveys for patients to track therapeutic goals. Some organizations grant prescribers access to foundation portals, allowing the prescribers to view reported dispenses, therapeutic survey responses, and funding balances.


During the genesis of foundations, reimbursement to pharmacies was slow and unpredictable. Organizations have since adopted technology solutions to provide faster and more regular reimbursement to pharmacies. Some foundations have adopted the NCPDP platform for adjudication and payment. These organizations work similarly to other secondary payer card solutions.

Debit cards that require activation per dispense have also been introduced as an option for payment. This solution allows the pharmacy to collect payment at the point of sale much like credit cards. A proprietary data standard has also been developed and utilized by some foundations. In this system, dispense data is passed from pharmacies to foundations through electronic data exchanges. With all of these solutions, reimbursement schedules are more predictable, accurate, and faster than with earlier systems.


As specialty therapies continue to become more complex, many organizations are being asked to assist with the many services that may accompany the ultimate delivery of the therapy. In the future, fundraising efforts may evolve to accommodate travel, administration services, diagnostic and genetic testing, and medical devices.


It is clear that copay organizations and specialty pharmacies foster similar goals. As the organizations continue to provide patients access to otherwise unaffordable therapies, the partnerships with specialty pharmacies will continue to grow in importance. Decreasing therapy initiation times and keeping patients on therapy are important components in the overall health care equation. Positively affecting a patient’s quality of life through these activities is an undeniably admirable result.

About the Author

Jon Kwiatkowski, RPh, is senior director, pharmacy services at CDF Rx.

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