The Copay Card Debate in Real Time

Representatives from the pharmaceutical industry and the managed care arena recently squared off at the 2013 Armada Specialty Pharmacy Summit about the costs and benefits of copay offset programs for biologics.

Representatives from the pharmaceutical industry and the managed care arena recently squared off at the 2013 Armada Specialty Pharmacy Summit about the costs and benefits of copay offset programs for biologics.

The debate about the use of copay cards for specialty medications came to life during a panel at the 2013 Armada Specialty Pharmacy Summit last week in Las Vegas, Nevada. Moderated by Mark Zitter of Zitter Health Insights, the panel paired a pharmaceutical manufacturer with a payer, allowing both sides of the copay debate to express their concerns.

Copay offset programs are “the new normal,” according to Zitter. There were 458 offset programs tracked as of March 2013, and nearly 80% of copay programs were for biologics, according to data from Zitter Health Insights’ Co-Pay Offset Monitor. Of the biologics that have copay programs, nearly 93% are for chronic conditions, he noted. Zitter stressed that cost-sharing can take a lot out of a patient’s monthly budget, and most copay card utilization (63%) is for high (tier 4 or above) preferred brand copays.

Steve Avey of MedImpact, who represented the payer side, noted that health plans are not insensitive to the burden that copays place on patients, but that patients nonetheless have to pay for some share of their medications. Jeff Krol of Avanir Pharmaceuticals, who represented the pharmaceutical manufacturer point of view, countered that copay cards are necessary to help patients get access to high-priced medications in the first place. “The patient out-of-pocket cost share is 43%, and it is growing every year,” Krol noted.

Avey argued that copay cards reduce motivation for patients to use the right drug, and drive utilization of non-preferred, branded products. This increases costs for employers, who may ultimately pass the bill on to plan members. Krol pointed out that without the cards, 1 of 3 patients walks away from the pharmacy with no drug at all because of prohibitive prices. “It’s not like we are trying to drive inappropriate use,” he said.

Specialty copay programs for drugs in crowded therapeutic classes offer the biggest savings opportunities, Zitter asserted. A rheumatoid arthritis drug such as Enbrel has among the highest offset opportunities, because it is associated with such high copays. Copay programs offset the majority of copay dollars and are often used where payer restrictions are greatest. Even so, said Zitter, most patients take advantage of just a fraction of available program benefits.

Zitter mentioned that copay programs have been shown to increase adherence, but Avey countered that at formulary committees, it all comes down to price. “If I can’t drive market share, I can’t get rebates,” Avey pointed out.

Despite their disagreements on the merits of copay cards, both participants agreed that specialty drugs should be filled at a specialty pharmacy, because adherence rates in this setting have been proven to be much better. But Avey pointed out that copay cards are keeping many patients who use specialty drugs in a retail environment. “Pharmacy is actually working against itself in that regard,” he added.

Payers and manufacturers are at odds about copay programs because both manufacturers and payers represent different business interests, and neither side is wholly altruistic, concluded Krol. “Ultimately, you must do what is right for the patient and the business.”