Three Questions to Ask Before You Recommend Alternative Funding for Pharmacy Benefits

Specialty medications can be life-changing for people diagnosed with debilitating or life-threatening conditions like lupus, hemophilia, and cancer. But for self-funded employers bearing the financial burden, the high cost of these specialty drugs can be challenging to absorb. Patient Assistance is top of mind for plan sponsors looking to shift specialty drug costs. When we polled benefit advisors at our State of the Industry 2023 webinar, about half of the audience reported clients ask about alternative funding the most, and 75% to 100% of their clients are dealing with a high-cost specialty medication concern today.

Employers want to provide robust pharmacy benefit coverage for their members while protecting their budget from a large, unexpected specialty claim. But factors like company benefits philosophy, patient mix, and drug mix need to be considered, and ultimately, patient assistance may only be right for some plans. Historically, we’ve seen issues with these programs because they are largely financially driven, sacrificing sound clinical management and quality member experience in pursuit of profit. Our preferred partner solutions paired with our Protect program address these issues — but even then, these solutions aren’t suitable for all clients.

Knowing when drug manufacturers’ medication assistance programs are viable solutions for your clients is vital to making the best recommendations to self-funded, carved-out employers. When educating a client on the available alternative funding methods, benefit advisors must evaluate the factors described above, plus the potential to lose substantial rebate dollars, the importance of clinical oversight, and the overall experience for members.

How will members be impacted?

Typical alternative funding arrangements exclude coverage of all or certain high-cost branded specialty drugs from the prescription benefit. Members may delay treatment for weeks while working with third parties to secure funding for their much-needed medications. The percentage of members impacted by these delays will be small — on average, only 2% of members represent 50% of pharmacy benefit spend — but the delay in care can have significant psychological and physical repercussions for the member, which could impact the employer far beyond the financial cost.

Patient Assistance solutions often have qualifying criteria members must meet to access funding. When evaluating programs, benefit advisors should determine if the programs use charity or manufacturer dollars and what the qualifying rules may mean for their client’s population.

Employers who value their teams and want to retain their workforce can’t afford to cut corners when it comes to clinical oversight to catch medications that shouldn’t have been prescribed in the first place. Nor can they afford the loss of valuable team members who leave in search of a better pharmacy benefit experience. With both point-of-sale short-fill and retroactive patient assistance partners, RxBenefits ensures members get their medications when needed.

Will necessary clinical oversight be integrated into the solution?

Benefit advisors have noted some patient assistance programs encourage members to stay on high-cost specialty medications when less-expensive options might be available. Our clinical experts know an independent review ensures each prescription’s medical necessity and appropriateness. When working with patient assistance solutions, your vendors should ensure medications are clinically sound and won’t have adverse effects or interactions with other prescriptions the member is taking.

When working with RxBenefits and our preferred partners’ Patient Assistance solutions, we require clients to enroll in our Protect suite of clinical programs. This ensures wasteful spending is rooted out. Protect provides strong clinical oversight for specialty medications and the other drugs these members take to coordinate care.

How will rebates be impacted?

Before adding an alternative funding solution to your clients’ pharmacy plan, it’s essential to consider how these changes will impact the plan overall. Discounts, rebates, and manufacturer copay assistance programs all play a role in managing specialty costs, and it’s possible to pull the wrong lever and lose savings elsewhere in the plan by implementing patient assistance.

Benefit advisors looking for the best contract value should consider how removing pieces of the puzzle and adding fees can actually increase specialty spending instead of finding promised savings. The key is analyzing the impact on other areas of the contract with an expert – especially when it comes to potentially lost rebates.

The right approach to managing specialty medication costs requires layers of protection 

There are pros and cons to Patient Assistance solutions, and there’s no one-size-fits-all approach to mitigating the cost and risk of specialty medications.

Evaluating your client’s pharmacy benefit needs for alternative funding can feel overwhelming. Find an independent partner who can help you answer these questions before making a recommendation:

• What specialty medications are driving the plan cost?
• How many members will be impacted by a change?
• What are the actual net savings?
• Will your partner provide independent clinical oversight and compassionate member experiences?

At RxBenefits, we’ve seen fundamental issues with a lack of clinical oversight, poor member experience, and impacts on rebates in most approaches to these solutions. We’ve found trusted partners who can help when Patient Assistance solutions make sense, but these solutions are part of a broader specialty medication management strategy. Programs that provide clinical oversight and traditional and supplemental pharmacy stop-loss can add layers of protection against specialty medication issues for plan sponsors.

Learn more about our Patient Assistance solutions.