Just when health plan managers start to feel that they solved the latest pharmacy benefit cost challenge, up pops a new one! Pharmaceutical manufacturers are motivated to spend advertising dollars on co-pay coupons designed to get around a health plan formulary and are coming at us in greater numbers than ever before. This is shifting predictable pharmacy benefit costs into the realm of the mysterious. No matter how one looks at the cost shifting outcomes, the results are clear: by using a co-pay coupon that reduces member cost to almost nothing, pharmaceutical manufacturers win by securing a customer for a brand name drug.
For compliance to chronic care medications, doctors are convinced that co-pay coupon cards improve medication adherence and save the member money. Many doctors hand out coupons in lieu of samples. Studies suggest that co-pay coupons foster compliance. Plan members are convinced that they are saving money when they can use a coupon for their prescription drug. But what are the hidden costs? Are those costs shifted to the plan and who ultimately pays for that cost shift? There is no simple answer without first examining all the variables as to how each scenario impacts the dollar spent by the health plan.
Safety and extended cost issues are apparent when the drug coupon runs out and brand loyalty has been established. When a coupon requires adjudication outside of the plan’s contracted PBM, oversight for adverse drug interactions goes away when the protection process of drug utilization review (DUR) is circumvented.
Each health plan design must be measured against possible coupon uses and should incorporate any of the “What if?” scenarios that impact the plan dollar. Some may be advantageous and some may be costly. Language must be explored that define how High Deductible Plans are funded when a coupon is part of the equation. PBM agreements should be reviewed to see what they allow. What does your retail pharmacy allow or require for coupon use?
Off-setting carefully thought out strategies for rational pharmaceutical use by co-pay coupons means that vigilant attention must be paid to the design and management of the plan’s pharmacy benefit going forward. APC can help with contracting and plan design to minimize potentially unforeseen bumps in the road to a successfully managed benefit.
