New Payer Policies Introduce Co-Pay Accumulators to Medical Benefit Products: Implications for Manufacturer Programs

In early October 2020, UnitedHealthcare (UHC) announced it will require network providers to report patient use of manufacturer copay assistance offers for products covered under the major medical benefit beginning in 2021. There is also speculation that other payers will follow suit and introduce similar policies. The result of these changes is that co-pay accumulators, which to date have been predominantly a pharmacy benefit issue, will now become a critical consideration for products covered under the medical benefit as well.

Manufacturers offering copay assistance for medical benefit products will need to incorporate accumulator mitigation strategies into their program design and establish monitoring capabilities to assess the impact of this new payer dynamic for their brand. While much remains to be seen about exactly how payers may implement policies like this, there are some specific areas brands should understand to best position themselves to effectively address this issue.

IMPACT TO PATIENTS

Like pharmacy benefit accumulator adjustments, patients stand to be significantly harmed by these types of payer policies. Across Mercalis' (formerly TrialCard) portfolio of medical benefit copay programs, the average per-claim benefit amount for 2020 is approximately $900. While program benefits and patient cost-sharing obligations vary greatly based on product profile and plan benefit design, this figure broadly highlights the critical importance copay assistance plays in facilitating patient access and adherence, especially with therapies for chronic conditions.

Not receiving credit for manufacturer assistance benefits will prevent patients from moving through their deductible period, leaving them with extensive out of pocket costs once the manufacturer offer has been exhausted. As the first payer to formally introduce this type of policy, UHC accounts for just under 11% of enrolled patients among the same collection of programs that Mercalis (formerly TrialCard) manages. Several other prominent, nationally recognized payers account for similar shares of overall medical benefit copay program patient participation, making it easy to envision the scope of negative patient impact if even a few additional payers follow UHC’s lead.

POTENTIAL FOR PROVIDERS TO DECREASE INTERACTION WITH CO-PAY PROGRAMS

The requirement stated in the UHC policy, which could be similarly imposed by other payers that follow, is that providers must report patient use of copay assistance offers. What may materialize in practice, however, could be slightly different. The reporting process outlined is complicated, encompassing multiple steps and technology interfaces.

Providers, already facing considerable challenges brought on by COVID-19, will be forced to stretch already thin resources to comply. Many may not have the administrative resources to follow these payer guidelines. In addition, the requirement creates a potential risk for providers in that incorrect reporting, or unintentional failure to report could jeopardize their network contract with the payer.

Providers may therefore choose to take the risk-averse stance that they will no longer participate in manufacturer copay programs, opting instead to simply inform patients that manufacturer assistance is available, but the patient must interact with the program on his or her own. Should this occur, manufacturers may need to reassess their program design in terms of how the patient enters the program and how claim submission and processing occurs, to ultimately drive effective participation.

DIRECT-TO-PATIENT ENGAGEMENT BECOMES KEY

Should manufacturers redesign their programs in a way to navigate reduced or discontinued provider participation in the claim submission process, the ability to engage directly with patients would become increasingly more critical. Informing patients of the impact of payer policy changes in plain language, so they understand why a process they may be familiar with is no longer available, is the first step to mitigating accumulator impact for products covered under medical benefit.

A direct-to-patient communication channel also enables manufacturers to guide patients through a new reimbursement process to minimize potential attrition due to a lack of understanding. Digital options that present patients with an avenue for two-way information exchange with the program could deliver increasing value for both educating and informing, as well as carrying out claim submission and reimbursement functions.

This is quite a paradigm shift; historically, manufacturers have not engaged directly with patients on provider-administered products and certainly not in the same way they have done so with self-administered drugs. Mercalis' (formerly TrialCard) Mango Health patient engagement program provides pharmaceutical manufacturers with a centralized platform to communicate directly with patients about these evolving policies and proposed mitigation offerings.

IMPACT TO PHARMACEUTICAL MANUFACTURERS

While much remains to be learned about how payers plan to implement policies like this, pharmaceutical manufacturers operating or considering copay assistance programs for products with medical benefit coverage should assess elements of their program design to pinpoint areas where modification might be necessary to address the impact of copay accumulators.

If left unaddressed, these new payer approaches have the potential to significantly increase manufacturers’ copay program reimbursement costs. In addition, with the final outcome of the June 2020 Centers for Medicare and Medicaid Services’ proposed rule regarding manufacturer coupon programs and best price reporting still undetermined, manufacturers face another looming threat to their financial tenability.

Mercalis (formerly TrialCard) is actively working with several pharmaceutical manufacturers to fully understand the potential implications of this issue and devise solutions for their medical benefit copay programs. To better understand how these new developments may impact your brand program and ways you can effectively address them to enable continued patient support, please contact us at sales@mercalis.com.

You can also join Mercalis' (formerly TrialCard) Jason Zemcik on Thursday, November 5th at 1 p.m. ET for a free live webinar Implications of Copay Accumulators on Medical Benefit-Covered Products.