Specialty-focused partial-fill plan designs are gaining traction, with conflicting opinions on whether they reduce waste or impact the quality of care.
What Is Partial Fill?
The term “partial fill” is not new to the pharmacy industry. Historically, partial fills were used by pharmacies when there was a supply deficit: a partial fill of a prescription was given to a patient while they were waiting for the remainder of the prescription to be available. This partial-fill model most frequently occurred with traditional small-molecule medications. More recently, partial fill has taken on a very different meaning.
Whereas traditional oral small-molecule medications are often distributed on a 90-day cycle, this has not been the case for specialty medications. Very few payers allow a 90-day fill of specialty medications. More often, payors have been utilizing a 30-day fill cycle. Over the last couple of years, however, the dispensing has further decreased, in some cases to 14 to 16 days. This is the world of partial fills.
Why Use a Partial Fill?
Although 90-day fills of medications have become common in the traditional pharmacy benefit management setting, there are some payers that have been reluctant to make that available to patients. Those that have not made 90-day fills available through plan design voiced their concern about the “stockpiling” and potential wastage of medications.
As specialty medications are fast replacing small-molecule medications in payor top 10 lists, the cost-control focus has turned. I am now hearing many similar concerns regarding medication wastage that we heard in the past. The difference comes in the price tag of the medication, as specialty drugs can frequently cost more than $100,000.
Payers with whom I work understand the opportunity that specialty medications afford patients who are utilizing them. Many of these medications address medical problems with unmet needs. Payors also understand the need to cover these medications; however, they do not want to fund medication waste. One way they are addressing this concern is through the use of a specialty-focused partial-fill plan design.
The Partial Fill Plan Design
Although partial fills for specialty drugs began just a few years ago, in the last couple of years, this plan design has gained traction. A recent study funded by EMD Serono found that 43% of plans were implementing designs that included partial fills. I have seen 2 major areas of variation within the plan design:
The specifics around a partial fill vary according to the benefit design attached to it, and whether the requirement is focused on first fill only or subsequent fills, as well. The large majority of organizations that utilize a partial-fill program focus on oral oncology medications. In addition to oncology, other organizations have taken a broader vision, and include anti-inflammatory, multiple sclerosis, and hepatitis C drugs, as well. In addition to variation in focus on certain medication classes, there is also variability on when the partial-fill plan design is in effect.
Almost half of the payors that utilize such a plan focus on the first fill. These organizations believe that this plan design has the greatest impact at the onset of treatment. There are other organizations, however, that believe a partial fill goes beyond efficacy and safety, utilizing it for subsequent fills, with a relatively small group utilizing a partial fill for all fills.
As I stated above, partial-refill plan designs vary. One of the reasons for this variation lies in the desired goal of the payer. In speaking with my clients I have found that reasons vary from financial focus and impact to clinical focus and a number of areas in between.
What Are the Opportunities of a Partial Fill?
Some say that a partial fill is really a reduction-of-waste program, while others have pointed out the potential for impact on quality of care. A third group sees a partial fill as a medication-support and education tool.
The reality is that depending on the services that surround the partial-fill plan design, it can be any or all 3. The best of the partial-fill programs have aspects that include:
What Are the Downsides of a Partial Fill?
There are 2 areas of concern associated with partial fill that have been identified. The first is a patient’s out-of-pocket costs. During the early evolution of partial fill, patients were required to pay a full month’s co-pay or coinsurance, while only receiving the partial-fill portion of the prescription.
This created a great deal of dissatisfaction and noise by patients. This payment model is rarely used today, and is no longer an issue. The second area of concern that has been identified is when there is little or no clinical interaction between the partial fill and the completion of the fill.
This partial-fill model can reduce unnecessary fill completion and, therefore, reduce costs; however, this misses an opportunity to potentially improve clinical outcomes, and support patients regarding medical conditions that often need significant clinical support.
I am a believer in a partial-fill plan design for specialty medications. I believe that this program supports plan members in getting the best potential outcome associated with their medication, while ensuring cost savings when a full fill of a medication is not necessary.
That being said, I advise my clients to work with their specialty pharmacy to ensure there are solid clinical programs included with this plan design.
What has been your experience with partial fills? Are they barriers to care or an improvement on care? I look forward to hearing from you.