Managing the Cost of Specialty Drugs
What is a Specialty Drug?
Medicare defines a specialty drug as one that costs more than $670 per month. In addition to high cost, these drugs are complex and generally treat complex or rare chronic conditions.
AARP reports that the “average specialty drug price reached $136,401 in 2020, rising more than three times faster than the prices of other goods and services. More than twice the median U.S. household income of $65,712.”. As costs increase along with higher life expectancies and soaring living costs, more patients are increasingly abandoning their pharmacy prescriptions. More than 375 patient assistance programs exist in the U.S., indicating that families with self-funded plans are experiencing financial challenges to some degree.
Cost-Effective Solutions to Help Plans and Plan Members
Several pharmaceutical companies and manufacturer-sponsored programs offer patient assistance programs to eligible employees. Assistance programs fall into two main categories: Copay Assistance Programs and Patient Assistance Plans, also known as Drug Assistance Programs. However, navigating through the complex application process and determining the differences between the assistance programs can be confusing and time-consuming. A medication access specialist or pharmacy solutions organization can assist your company in finding the best supporting plan for your employees, connect you with international pharmacies for lower medication prices, and reduce your health plan expenditure.
What Are Copay Assistance Programs (CAP)?
A Copay Assistant Program (CAP) is essentially a copay assistance card that patients use to pay for their out-of-pocket costs for specialty drugs. Any patient who has private health insurance, except for Medicare or Medicaid, can apply; however, program restrictions vary. A CAP is designed to help lower-income patients; therefore, highly compensated employees can expect limited access. A copay assistance card is also referred to as a CAP or a copay coupon that helps cover the amount not covered by your health insurance, thereby making the medication less expensive.
What are Patient Assistance Programs (PAP)?
A Patient Assistance Program (PAP) supports patients who can't afford medical insurance and meet the eligibility requirements, typically for needy or low-income patients that can demonstrate their financial need based on a set income and asset limitations. The responsibility lies with the individual or the employer in researching and understanding the eligibility criteria, as the application processes for specific programs differ. The best way to check for eligibility is to check the manufacturer's website. Another option is to search for the drug name at RXAssist.org, a nationally recognized, reliable resource for finding program information and criteria. RXOutreach.com is a non-profit mail-order pharmacy that offers generic medications at a discounted rate for qualifying patients who can prove a household income below 300% of the federal poverty level.
Bridging the Gap
The need for patient assistance programs has increased 32% since 2009 and is growing at an increasing rate. A CAP or PAP can help your employees continue their specialty drugs prescriptions for your organization's benefit and theirs.
PBA and its PBM partners work with both the plan and the plan member to take advantage of these programs.
About PBA
Professional Benefit Administrators, Inc. (PBA) is an independently owned and operated Third Party Administrator (TPA) with a national presence. Since 1985, PBA has been entirely focused on self-funded employer sponsored health plans. Our goal is to build relationships with advisors who believe in the value of self-funding health plans with a flexible, client centric TPA. Committed to leveraging the PBA Advantage, we offer a competitive edge and always search for innovation to break through the status quo.