Would Alternative Funding Help You Afford Your Members’ Specialty Meds?

For people with debilitating or life-threatening conditions like lupus, hemophilia, and cancer, specialty medications can be life-changing. But when self-funded employers are the ones bearing that financial burden, the high cost of those drugs can be hard to absorb. Alternative funding options are top of mind for many employers looking for other ways to handle specialty costs, and Patient Assistance is at the top of the list.

That said, Patient Assistance isn’t right for every plan. Factors like company benefits philosophy, patient mix, and drug mix all need to be taken into account, as well as other considerations like the potential to lose rebate dollars, the importance of clinical oversight, and the overall experience for members. A few questions to ask yourself:

How will my members be impacted?

Typical Patient Assistance arrangements will exclude coverage of all or certain high-cost specialty drugs from the prescription benefit. This can leave members without their much-needed treatment for weeks while they work with third parties to secure funding. And that delay in care can have major repercussions for the member, which could create issues for their employer far beyond the financial cost.

Employers who want the best for their teams can’t afford to cut corners when it comes to clinical oversight or member experience. It’s important to identify drugs that have been prescribed incorrectly, or shouldn’t have been prescribed in the first place, and prevent them from being dispensed. And it’s also important to have access to resources like point-of-sale short fills – a courtesy fill for a less-than-30-day supply – to make sure the member gets the treatment they need while funding options are being explored.

Will clinical oversight be integrated into the Patient Assistance solution?

Some Patient Assistance programs encourage members to stay on their high-cost specialty meds even when equally effective, less-expensive alternatives are available. Clinical oversight in the form of independent reviews can ensure every prescription is both medically necessary and appropriate. Your Patient Assistance vendor should have that oversight included as part of the solution to make sure the prescriptions are clinically sound and won’t interfere with any other prescriptions the patient is taking.

How will rebates be impacted?

Before adding any alternative funding solution to your pharmacy plan, it’s important to consider how that change will impact the overall plan. You could be relying on discounts, rebates, and manufacturer copay assistance programs to help manage your specialty costs, and if you pull the wrong lever, you could lose savings somewhere else in the plan when you implement Patient Assistance. Be sure to talk with your benefit advisor about analyzing your plan to verify you won’t lose rebates and take on added fees in your effort to save money on specialty drugs.

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

Every Patient Assistance solution comes with pros and cons, and you won’t find any one-size-fits-all approach to managing the cost and risk associated with specialty meds. At RxBenefits, we’ve seen major issues like a lack of clinical oversight, poor member experience, and impact on rebates in most approaches to this kind of solution. We’ve found trusted partners who can help when Patient Assistance solutions are a good choice, but those solutions are just one part of a much broader specialty med management strategy. Adding solutions that provide clinical oversight and traditional and pharmacy stop-loss can add extra layers of protection for employers.

If you think Patient Assistance might be a good choice for helping you manage specialty medication costs, talk to your broker about analyzing your pharmacy plan and evaluating potential Patient Assistance partners.