Copay Offset Programs: Blessing or Curse?

Cincinnati—Copay offset programs are seen as both positive and negative, according to Mark Zitter, founder and CEO of The Zitter Group. In a Contemporary Issues session at the AMCP meeting, Mr. Zitter gave a presentation titled The Growth of Copay Offset Programs: Implications for Managed Care Pharmacy.

He began by stating that the majority of promoted brands have copay offset programs (COPs). Among biologics, 69% of brands have COPs; among nonbiologics, 44% have COPs. There is variation in the use of COPs among manufacturers, with the number of brands with COPs ranging from 37 (Pfizer Inc.) to 6 (Astellas Pharma Inc.).

The types of COPs and the range of maximum benefits vary by therapeutic area, Mr. Zitter continued. There are 38 products for the treatment of dermatitis/acne that have a COP, 22 for diabetes, 17 each for cholesterol issues and cancer treatment, and 11 pain medications, for example. For dermatitis/acne treatments, the maximum benefit per fill is $200, for diabetes, it is $250, $100 for cholesterol control, and $150 for asthma. COP benefits also vary within categories, Mr. Zitter said. For medications for the treatment of rheumatoid arthritis, for example, the maximum annual COP benefit ranges from $11,500 for Cimzia^® (certolizumab pegol) to $3500 for Actemra^®(tocilizumab).

Mr. Zitter said there are 3 types of COPs. He defined them as (1) save up to, (2) pay only/pay no more than, and (3) free trial offer. In the save up to scenario (“Save up to $15 per qualified prescription”), the COP’s benefit to the patient is a fixed dollar or percentage amount of the co-pay, and the patient pays some variation of the balance. In the pay only/pay no more than version (“Pay no more than $25 per qualified prescription”), the program entails a buy down to a fixed price or percentage. Finally, for free trial offers, the patient is entitled to one or more free fills. Free trial offers may be combined with other offer types following the initial free trial fill, Mr. Zitter said.

The pay only and save up to models predominate in the current marketplace. Of 417 programs identified, 45% were pay only, 33% were save up to, 11% were free trial offers, and 2% were free trial offers and at least 1 refill (9% were NA).

The majority of COPs are for medications that do not have a direct generic available (97% of 439 programs surveyed were with drugs with no direct generic).

Physicians are supporters of COPs, Mr. Zitter continued. Of 43 physicians surveyed (20 rheumatologists and 23 general practitioners), 86% agreed with the statement “In my experience, co-pay offset programs have improved patient trial or uptake.” Likewise, 86% agreed with the statement, “In my experience, co-pay offset programs have improved my patients’ adherence with the drug regimen,” and 91% agreed with the statement “I believe co-pay offset programs increase my patients’ access to the drug.”

The same 43 physicians were asked how COPs would impact their prescribing behavior. Seventy-two percent said they were likely to “choose one drug with a copay offset program over one without a copay offset program, assuming both drugs are equal from a clinical and payer control perspective.” Fifty-one percent agreed with the statement, “My patients have requested that I switch from their current drug to another one with a copay offset program,” and 47% answered “yes” to the question “have you ever initiated switching a patient from one drug to another solely due to a copay offset program?” When asked about the likelihood that they would enroll a patient in a copay offset program for a drug they had never prescribed before, 70% said they were likely to very likely.

Feedback from patients indicated that COPs helped them increase their compliance rates, with 68% responding that they agreed to strongly agreed with the statement, “I think that copay offset programs have helped me be more compliant in taking my medications.” When asked if they agreed with the statement, “I would ask my doctor to switch from a current drug to one that offered a copay offset program,” 55% agreed or strongly agreed.

When pharmacists were surveyed on COPs, 30% estimated that 6% to 10% of the prescriptions at their pharmacy were filled with COPs. The pharmacists indicated that COPs can present some problems, including patients providing  unactivated copay cards, discontinuation of the program without notice, or the patient neglects to provide the card when having the prescription filled.

Mr. Zitter then turned to the managed care implications of COPs. He reported results of a survey of 101 payers. When asked about commercial COPs for orphan drugs to treat a rare disease, 43% were somewhat or strongly supportive. When asked about COPs for brands with generic alternatives within the same therapeutic class, 79% were strongly opposed.

Some payers have taken action against COPs. Of those surveyed, 59% said they have increased the use of step edits for nonpreferred branded drugs, 43% said they have moved nonpreferred branded drugs to a higher tier, and 29% have increased the use of step edits for preferred branded drugs. However, most have not responded to any individual drug’s COP.

Mr. Zitter concluded by outlining such opportunities for payers and manufacturers to partner in the COP domain as reducing barriers to preferred products; developing patient access solutions in high-cost categories; developing adherence solutions in all categories; and sharing data related to co-pay sensitivity and the impact of various interventions, by category.

He noted that 54% of payers would be somewhat or strongly supportive of working with manufacturers to distribute COP offers for orphan drugs for rare diseases; 43% said they would be somewhat or strongly supportive for preferred brands in categories with no generic competition.