Beyond Payment Methods

Copay accumulators and best price impact present a complicated challenge for patient-support services leaders. Much of the focus in addressing this issue has been on reimbursement methods that can be used. Providing benefit outside of the pharmacy claim is central to mitigating the impacts of accumulators and avoiding best price exposure when the Centers for Medicare and Medicaid Services (CMS) Final Rule on manufacturer coupons goes into effect on Jan. 1, 2023.

Not to be overlooked is the importance of ancillary supporting services. Neglecting other areas can cause even the most well-designed reimbursement process to fail. This issue has caused a synthesis of patient affordability, and support services are necessary to deliver an offering that is compliant, effective in mitigating out-of-pocket obligation, and minimizes patient burden.

Patient education: Navigating a new program experience

Pharmacy benefit copay programs are efficient for patients to use. A chief concern among pharma manufacturers is that efforts to mitigate copay accumulator issues and in manufacturer compliance with the CMS Final Rule will burden patients and lead to abandonment.

Patient communication is a critical element of any accumulator and best price strategy. While so much focus is on operational design, ensuring patients can navigate program changes is vital to achieving success. Manufacturers should plan advance communications to patients that will alert them to program changes. These messages need to inform the patient that their experience will look different in the months ahead, while also providing reassurance that the manufacturer will still support their cost-sharing obligations.

When the revised program goes live, patient education is even more critical. Step-by-step education points for hub agents to walk patients through can be the difference between confusion and a smooth transition. Guidance on how to submit claims for post-transaction rebates, proper documentation, and how to select the preferred method of reimbursement from programs that offer multiple avenues are foundational components of this outreach.

Another best practice is to establish a frequently asked questions repository for agents to use in responding to inbound patient escalation inquiries. Updating this library on an ongoing basis and conducting training sessions to cover trends not only improves the support element but can help the manufacturer and copay program provider identify opportunities for program adjustments.

Benefits investigation: Customizing program value

The integration of eServices and copay assistance is a pairing whose time has come. Incorporating benefit investigations to determine a patient’s out-of-pocket responsibility allows the manufacturer to design program rules to only fund benefits in line with the patient’s need. This reduces the manufacturer’s financial exposure, as opposed to having a single copay program benefit limit that may be more generous than the patient needs.

Determining out-of-pocket obligation on each claim can also be a critical component of a best price solution for a specific subset of patients. In the Final Rule, CMS cites a rebate model to be compliant with the requirement to “ensure” benefit goes only to the patient. Some patients simply will not be able to make the upfront cost outlay necessary to participate.

Manufacturers have considered various methods of pre-funding or advancing funds to support these patients. This brings with it certain challenges. Provide the patient with too little and they may not be able to make their required payment. Overfund by too much and the company may encounter tax liability risks. A strong reconciliation process must be in place, one in which patients submit documentation showing proper use of any advanced funds to pay their pharmacy bill. This offers some control measures, but the baseline needs to know the patient’s specific out-of-pocket responsibility at the time of the claim still exists.

Manufacturers face a difficult challenge due to the CMS Final Rule. They must focus their program designs on an all-encompassing suite of support services to most effectively provide patient assistance in a compliant manner.

About the Author

Jason Zemcik is Vice President, Patient Affordability Practice Lead, TrialCard.