What is the difference between manufacturer coupons and patient assistance?

In today’s healthcare landscape, rising drug prices have become a significant concern for plan sponsors who strive to provide affordable pharmacy benefits to their members. To mitigate these costs, plan sponsors often turn to manufacturer copay assistance programs (MCAP) and patient assistance programs. While both programs provide financial assistance for patients, it is crucial to understand the fundamental differences between them in order to make informed recommendations. In this article, we will explore the differences between manufacturer coupons and patient assistance programs.

Manufacturer Coupons: Lowering Out-of-Pocket Costs

Manufacturer discount coupon programs are a common strategy employed by pharmaceutical drug makers to promote their brand-name drugs and encourage prescribers and patients to choose their products. These drug coupons are designed to reduce out-of-pocket expenses for patients and are administered at the point of sale through the employer-provided pharmacy benefit. Manufacturer coupons are also referred to as cost-sharing coupons, copay coupons or copay assistance cards. Copay coupons are typically for expensive, brand-name prescription drugs that don’t have a generic equivalent.

Patients are required to answer a few questions regarding their enrollment eligibility. Once enrolled, anyone prescribed the applicable specialty or non-specialty medications can utilize these coupons. They can be found at the doctor’s office or accessed online. Copay coupons are banned in Medicare and Medicaid or other government insurance plans. Manufacturer coupons are used in conjunction with your health insurance. The drug manufacturer charges your health plan its normal portion of the drug cost, but the patient doesn’t pay their normal co-pay share.

While pharmaceutical company copay assistance programs can lower the overall cost of the plan, a fee of 25% of the savings is usually applied. It is important to note that these coupons, processed as part of the pharmacy benefit, do not impact the contract value or member medication access. Moreover, plan sponsors can maximize the benefits of copay assistance by implementing copay accumulator programs, which ensure that only the member’s contribution accumulates towards the deductible and maximum out-of-pocket expenses. By combining accumulator protection programs and copay maximizer programs, employers can effectively reduce the high costs of medications while enabling members to access necessary drugs at a lower out-of-pocket cost.

Patient Assistance Programs (PAPS): Targeted Support for Underinsured Patients

Patient Assistance solutions, on the other hand, aim to alleviate the financial burden of specialty drug costs. Unlike drug company copay assistance programs, these funds are not available to all members. Instead, they are based on income and need, and can only be accessed by underinsured or uninsured patients. These funds are typically provided by pharmaceutical manufacturers or a non-profit organization that covers the cost of certain medications for eligible individuals.

To determine eligibility for Patient Assistance, patients are required to submit an application that demands more extensive information compared to manufacturer coupons. This includes providing financial documentation such as pay stubs or tax returns for the family. Processing a patient’s application can take around two to four weeks or even longer, during which time members often require an alternative means to fill their prescriptions.

Medications funded through Patient Assistance solutions cannot be processed through the employer-provided pharmacy plan. Members qualify as underinsured because their plan does not cover these specific medications. When considering the adoption of Patient Assistance solutions, plan sponsors should take into account factors such as company benefits philosophy, patient mix, and drug mix. Removing a specialty drug from a plan’s coverage can impact both the member and the contract value with the pharmacy benefit manager (PBM). The savings achieved through these programs depend on the drug mix and the conversion rate to patient assistance. While substantial savings can be achieved, it is important to consider the potential loss in contract value if the conversion rate is low or if the right drugs do not convert.

These programs can be combined, allowing members who are not eligible for patient assistance to still benefit from manufacturer assistance in lowering costs. It is essential for plan sponsors to have a comprehensive understanding of the realistic savings potential, impact on the contract, and member experience in order to select the program that provides the greatest benefit.

The Importance of Clinical Oversight

Both manufacturer copay assistance programs and patient assistance solutions require independent clinical oversight to protect plan sponsors and their members. Clinical oversight ensures that the prescribed medication is the most appropriate therapy for each member and their specific disease state. By implementing clinical oversight, plan sponsors can ensure that the plan only pays for necessary medications, avoiding the potential wastage of funds on unnecessary or less cost-effective drugs.

Without clinical oversight, patients may be prescribed medications that are not the optimal choice for their condition. Alternatively, a lower-cost drug that does not require assistance programs may be available. Therefore, clinical oversight plays a crucial role in optimizing the healthcare outcomes for members while controlling costs for plan sponsors.

In conclusion, while both manufacturer coupons and patient assistance programs aim to alleviate the financial burden on patients for prescription drug costs, they differ significantly in their qualifications, impact, and intent. Manufacturer coupons lower out-of-pocket costs for all eligible patients, while patient assistance solutions target underinsured individuals based on income and need. Plan sponsors must carefully consider various factors such as company benefits philosophy, patient mix, and drug mix when implementing these programs. Additionally, it is imperative to have independent clinical oversight to ensure that the prescribed medications are appropriate for each member’s condition

Sources

• Pharmaceutical Manufacturer Patient Assistance Program Information – CMS