Finding Prescription Affordability Options Amid a Flood of Cards  

Patients are looking for ways to save money on prescriptions — specifically, their prescriptions. While myriad options exist to help improve medication access through lower prices, it can be hard to know — for patients and their care teams — which option is best.

Affordability options for preferred medications can be critical for patient adherence. And those on Medicare Part D plans have to dance with the infamous “donut hole,” a period after initial coverage and before the patient spends enough out of pocket to reach “catastrophic coverage.” While the patient responsibility for drug cost has dropped from 100 percent to 25 percent this past year, the $6,550 requirement for catastrophic coverage isn’t a drop in the bucket for most people.^[1]Prescription drug coverage gaps explained: the Medicare Part D 'donut hole', Humana, 2021

Patients can use biopharma company copay cards or cash discount cards to lower out-of-pocket costs on medications. However, a recent CoverMyMeds survey shows 37 percent of patients are unaware discount programs exist, even though use of copay cards has become increasingly common in the last decade.^[2]CoverMyMeds Patient Survey, 2020 Care team members and patient-facing technology can connect patients to card programs to help lower prescription costs — and assist them in choosing the right one out of hundreds in the market. But where to start?

Editor: This is the first article in a three-part series about prescription affordability options. You can find the other two articles here:

• How to Help Your Patients with Biopharma Copay Cards(https://insights.covermymeds.com/patient-experience/affordability/how-to-help-your-patients-with-manufacturer-copay-cards?_gl=19399cr_gaMTU1MzE1ODg1OC4xNjY1NTE2NTkx_ga_FNV852Y540MTY2NjE4ODMzMy4zLjEuMTY2NjE4ODU5OC4wLjAuMA.. "How to Help Your Patients with Biopharma Copay Cards")*
• Cash or Bust: Why Discount Cards Could Be Key to Medication Adherence

Copay and discount cards: What’s the difference? 

Both are cards used at the pharmacy. Both can save patients money on prescription costs. So, what’s the difference and why does it matter?

Copay cards

Copay cards are provided by the biopharma company to help lower or sometimes eliminate patient costs for a drug at the pharmacy counter. They must be used in combination with insurance and are usually run as a secondary insurance.

For the biopharma company, copay cards can give patients a reason to choose brand drugs over generics by taking the expense factor out of the decision equation. They also still get paid for the drug through the portion insurance covers.

Discount cards

Drug discount cards are typically realized through a partnership among pharmacy benefit managers (PBMs), pharmacies and third-party marketing organizations. These third parties often aggregate discounts from several PBMs that have a network of pharmacies they work with.

When using a discount card, patients forego their insurance and pay the remainder of the prescription balance out of pocket. Partnered pharmacies pay a fee to PBMs to participate in the discount card program. For the pharmacy, these cards can serve as a marketing channel, connecting more patients to their location that accepts the discount card.

Discount cards are an option for the under- or uninsured 

In a study by the University of Southern California, researchers used pharmacy claims data from a large commercial insurer, combined with national average drug reimbursement data, to identify claims where patients overpaid for their prescriptions. The study found nearly one in four patients were overpaying for their prescriptions by using their insurance instead of paying cash.^[3]Overpaying for Prescription Drugs: The Copay Clawback Phenomenon, USC Schaeffer, 2018

For some patients, paying cash is the best option for prescription affordability. Individuals on high-deductible plans will pay at least $1,400 out of pocket before reaching their deductible — for those on family plans, it’s $2,800.^[4]High Deductible Health Plan, Healthcare.gov, 2021 Many patients may consider forgoing insurance to pay for medications since they’re unlikely to hit their deductible within the year anyway.  

In our survey, when a prescription cost more than expected, 43 percent of patients searched on their own for a cash price outside of insurance while only 23 percent asked their provider or pharmacist about the cash price.^[2]CoverMyMeds Patient Survey, 2020 Discount cards can offer patients a sense of choice and ownership in their individual path to medication access.

Copay cards can provide relief for patients on brand therapies 

While 9 out of 10 prescriptions filled every year are for generic drugs, the remaining 10 percent still accounts for millions of brand prescriptions.^[5]Generic Drugs, U.S. Food & Drug Administration, 2020 While more expensive than their generic equivalents, many brands don’t yet have an equivalent, and yet are provider- and patient-preferred drugs.

In one study, 79 percent of brand drugs with copay cards had no generic equivalent, making the card more of an affordability lifeline for many patients.^[6]A Perspective on Prescription Drug Copayment Coupons, USC Schaeffer, 2018 An IQVIA analysis found new patient abandonment rates are 50 percent lower when copay cards are used compared to what they would have been without a copay card.^[7]Patient Affordability Part Two, IQVIA, 2018

A word on CAAPs

In 2018, PBMs launched copay accumulator adjustment programs (CAAPs) that prevented funds from copay cards from being applied to patient deductibles. This move can be especially concerning for those on high-deductible plans who are already responsible for a large portion of their medical and prescription expenses for a large part of the year.

Without copay card funds counting toward their deductible, prescription costs could become prohibitive, causing some patients to either abandon their medication or switch to a less-preferred alternative.

In one study, patients on high-deductible plans impacted by CAAPs had 1.5 fewer prescription fills than those on high-deductible plans without a CAAP over the course of nine months.^[8]RxCrossroads by McKesson data, 2018 With formulary and benefit changes yearly, many patients may be unaware their insurance has a CAAP until their copay card runs out and a large portion of their deductible remains.

Currently, five states have passed laws restricting CAAPs to varying degrees and more are likely to follow this year. Intelligent technology can help identify and predict plans impacted by CAAPs to help potentially impacted patients create a financial game plan and stay adherent to their medications.

Technology can help providers, pharmacists and biopharma assist patients with affordability 

Deciding the best route to medication access, affordability and adherence can feel like fanning out a hand of cards at the point of prescribing.

While care teams at the prescriber’s office and pharmacy can hold personal conversations with patients, transparent, real-time tools delivered within the prescriber and pharmacy workflow can help lay all the cards on the table for an informed decision-making process. Additionally, patients that opt-in to receive education and outreach when they enroll into co-pay card programs provides a direct-to-patient channel for education and engagement. This transparency can help determine decisions like generic or brand medications, payment through cash or benefit, and which affordability assistance tool is available for use.

Biopharma company educational material, often available with copay cards, can further help patients better understand their condition and medication to improve adherence.

Read more about state legislation impacting patient medication affordability options in our 2021 Medication Access Report Legislative & Regulatory Edition.