Because Pfizer used the phrasing “pay no more than” $15 or $20 rather than “pay as little as” those amounts in copay cards for three of its branded products, the New York State Attorney General received complaints from consumers who found that they had to make additional payments when presenting the coupons at pharmacy counters. After an investigation and negotiations with Pfizer, the company has agreed to a $500,000 penalty and $200,000 in restitution to state residents who were injured, according to an NYS AG statement.
From the outside, it appears that Pfizer marketers didn’t take into account the various ways pharmacy benefit managers (PBMs) and insurers structure their copay programs, which generally require patients to pay a fee when obtaining drugs; they can vary by drug, by insurance plan and even by time of year for the patient. Copays, of course, have been a grating friction point with patients and the entire US healthcare system, especially after insurance plans developed in the wake of the Affordable Care Act jacked up copays for both drugs and medical procedures. PBMs maintain that pharma-sponsored coupons are merely a way to encourage patients to stick with expensive branded products when other, less expensive products would work as well; pharma asserts that coupons enable patient to stay on therapy in the face of onerous copays.
Pharma financial managers need to balance what they’re willing to rebate to PBMs to get on formulary, versus how far they’ll support patients’ out-of-pocket expenses. The latest plane of battle is copay accumulators, by which PBMs add the value of the coupon support to patients’ annual insurance deductible, in effect negating the coupon for some patients. (Coincidentally, CBI Events is sponsoring a one-day meeting on copay accumulators in December.)
The NYS AG indicates that Pfizer has already addressed the sloppy language by using “pay as little as” wording on its agreements going forward. And while it’s speculative to say so, the AG action is not a direct blow to the concept of copay programs; but it’s within the realm of possibility that other states will follow New York’s lead in reviewing the programs more closely, and penalizing pharma companies where they can.