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Specialty drug coupon exclusions

Specialty medications represent the fastest-growing part of pharmacy spend. Of the top 100 prescription drugs, one-half are now specialty medications and they represent fully one third of client prescription costs. 1,2 By 2016, it is estimated that 8 of the top 10 drugs will be specialty drugs.1

Manufacturer copay programs that pay most or all of a member’s medication cost exist for nearly all specialty drugs.1 While coupons are often defended on the grounds that they protect access to medications – especially for expensive specialty medications – in most cases, the discount cards are available to any member, regardless of financial need.3

We should note that coupons are not universally accepted as a legitimate business practice. Federal programs like Medicare do not permit the use of coupons, nor do most mail order programs, including OptumRx.

A lawsuit is currently pending against eight pharmaceutical manufacturers regarding their use of coupons. The suit alleges that coupons raise health insurance premiums and that they cause plans to pay much more when a more cost-effective and clinically safe drug is available.

Coupons ultimately add costs back into the health care system by circumventing tiered Prescription Drug Lists (PDLs) that encourage use of lower-cost medications. For example, Genetech’s assistance card for CellCept® will pay a member’s copayment up to $100 each month, effectively eliminating the average $55 Tier 3 cost.

While coupons make CellCept more affordable for the member than our lower-tier PDL agents, such as mycophenolate, they do nothing to change the true cost of the drug. The difference is that more members will use the non-preferred CellCept because of the discount, with the greater cost being incurred by the employer or plan — which may ultimately increase costs for all.

Analysis of UnitedHealthcare claims shows that coupon use is widespread:

  • 75 percent of members on a Tier 3 drug are using a copay coupon.
  • 45 percent of members take a Tier 3 specialty drug even when a Tier 1 or 2 option is available. 2

A new policy

In an effort to manage rising medication costs, UnitedHealthcare’s Specialty Designated Pharmacy Network will no longer redeem manufacturer-provided coupon cards for these Tier 3 specialty drugs beginning January 1, 2013:

Important points about this policy

First, while most pharmacy benefit managers place all specialty drugs in the highest tier, we place specialty drugs in tiers based on the specific health care value each one delivers. As the grid shows, this means that we have Tier 2 specialty drugs in every impacted category, which lessens the financial impact to members.

Second, in most cases a member’s cost-share will be similar for a lower-cost option as it would be with these coupons.

Implementation

While fewer than one percent of members currently take one of the targeted medications, we will work proactively to inform them of this change and their options:

  • Beginning in early November we will send letters and make phone calls to these members, informing them of the change.
  • When members call to refill their prescription in December, customer service representatives will be prepared to discuss the availability of lower-cost options.
  • Specialty pharmacists are available to discuss alternatives with the member and work with physicians to get new prescriptions.

On Jan. 1, network specialty pharmacies will no longer accept coupon cards when a member calls to fill a prescription.

Supporting employer plans

We believe that removing the financial incentives provided by coupons will help support employer benefit design strategies and motivate members to choose one of their lower-cost options. This supports our goal to manage the cost of healthcare, while ensuring affordable options for members.

1. Atlantic Information Services, Inc., (AIS): Health Plan Strategies to Combat Consumer Drug Copay Coupons. April 26, 2012

2. UnitedHealthcare claims data.

3. Visante/Pharmaceutical Care Management Association. How Copay Coupons Could Raise Prescription Drug Costs By $32 Billion Over the Next Decade. November 2011.

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