Affordability remains a major challenge for patients prescribed specialty therapy, as costs for these medications continue to climb. Though patient assistance programs (PAPs) can cover specialty drug costs for patients who are low-income, uninsured, or underinsured, patients who don’t meet those eligibility criteria are often left facing potentially cost-prohibitive pharmacy bills.
As the specialty therapy market is estimated to grow from $336 billion in 2018 to over $475 billion by 2023 across developed markets, copay programs have become an important vehicle for removing cost barriers for those patients. By using digital hub services to administer and manage these copay programs, manufacturers can offer this much-needed benefit in a more streamlined, efficient way.
Easing the Burden
Unlike many drugs that require a relatively inexpensive, flat copay fee, most specialty drugs are on Tier 4 or 5 of an insurer’s formulary, and thus subject to deductibles and coinsurance. With some insurance plans assessing high deductibles, along with coinsurance rates of up to 30 percent or more, the associated out-of-pocket costs can prove out of reach for many patients. Many pharmaceutical manufacturers offer copay assistance programs, also called copay cards or copay coupons, to prevent high out-of-pocket costs from encouraging patients to fail to initiate or abandon treatment.
Streamlining the Workflow
As with most processes in the healthcare industry, properly managing that pharmacy program per the manufacturer’s guidelines from start to finish involves multiple steps and entities. And when that process is handled manually, it can become labor-intensive, time-consuming, and prone to errors.
That’s why pharmaceutical manufacturers that are looking to streamline and simplify the administration and management of their pharmacy copay programs often turn to hub services technology. By automating the entire front-end workflow of a co-pay program—from evaluating patient eligibility, to enrolling qualified patients, to managing claims processing and reimbursement—hub services technology can greatly improve the experience for patients, providers, and specialty pharmacies alike.
A Patient-Centric Approach
When a manufacturer’s pharmacy co-pay program is integrated with hub services technology like the CareMetx platform, the workflow is configured and tailored to the manufacturer’s specific needs and specifications- but it all starts with, and maintains focus on: the patient.
First, CareMetx works to ensure that patients who qualify for and can benefit from this valued service are identified and enrolled in accordance with the manufacturer’s eligibility criteria. Whether the patient learns about the copay program from a provider, a patient-facing website specific to their therapy, or at the point of filling the prescription, the process needs to begin with an accurate assessment of eligibility.
Since each manufacturer sets their own pharmacy copay program eligibility criteria, establishing and executing against the manufacturer’s business rules is essential to ensuring only patients who qualify are enrolled.
Once CareMetx receives an enrollment request, several activities occur, all guided by an electronic, automated process:
- The required information is obtained from the patient, either through a provider portal, by fax, or by phone.
- The patient data is electronically transmitted or entered into the CareMetx Digital Hub.
- The CareMetx Digital Hub uses an intelligent rules engine to execute on the manufacturer’s eligibility criteria, then returns a real-time decision on whether the patient qualifies for the copay program to ensure program compliance.
- An approval or denial letter is generated and sent to the patient.
- Our dedicated CareMetx Hub support team may also reach out to the patient by phone to discuss their eligibility, and answer questions.
- Depending on how the manufacturer has chosen to set up their co-pay program, the hub services system might also automatically inform the specialty pharmacy or treatment center directly about the patient’s eligibility status.
- If the patient is deemed eligible, they’re enrolled in the program and a copay card is generated (either virtual or hard copy).
Once enrolled in the copay program, the patient experience at the point of initiating or refilling a prescription is equally streamlined. With a copay card on file, the specialty pharmacy or treatment center simply runs the card to determine how much of a copay (if any) the patient is responsible for.
Ensuring Accurate Claims
While it’s critical to ensure that patients are properly screened for eligibility and enrolled in the copay program quickly and efficiently, it’s equally vital to ensure copay claims are processed and settled accurately and quickly.
Let’s say a patient’s insurance plan will cover the drug at 100% once the patient has paid copays or coinsurance totaling $2,000. The pharmaceutical manufacturer will thus want to be sure that only copay claims totaling $2,000 are paid out for the patient on that drug. Any claims beyond that threshold wouldn’t be valid based on the patient’s insurance benefits.
Manufacturers that use an automated workflow for their pharmacy copay programs often rely on hub services technology to streamline and simplify these essential claims-related functions as well, such as:
- Adjudicating the copay claim electronically through a direct API connection to the payer
- Keeping track of the dollar value of copay claims processed for a given patient and drug, to ensure the manufacturer isn’t billed for claims exceeding the eligible amount
- Generating reports on patient copay program enrollment and usage, to help the manufacturer maintain regulatory compliance
Delivering a Better Experience
With costly specialty drugs representing an estimated 52 percent of pharmacy spend, copay programs will continue to prove essential to reducing the cost burden for patients, encouraging them to initiate much-needed therapies, and ensuring they adhere to their treatment plans. Manufacturers will increasingly turn to automated copay program solutions to streamline and simplify the front-end workflow associated with offering these vital assistance programs.
As the healthcare industry continues its digital transformation, CareMetx remains committed to providing the technology platform and digital capabilities that are central to improving efficiencies, streamlining workflows, and improving the patient experience. Our copay solution is just one of many offerings that help pharmaceutical manufacturers achieve these objectives.
Contact CareMetx to learn how our full line of e-services and robust hub services platform are transforming patient access and affordability, while delivering radical efficiencies for our clients.