How a specialty pharmacy can help support patients that utilize copay assistance

What is copay assistance and why does it exist?

Copay assistance is a financial support program designed to help individuals with the cost of prescription medications. It typically involves a third party, usually a pharmaceutical manufacturer or a charitable organization, providing financial support to cover some or all of the out-of-pocket expenses that patients would normally be required to pay when filling a prescription or receiving medical services. Out-of-pocket expenses include copayments, deductibles, coinsurance or other cost-sharing requirements dictated by a patient’s benefit design.

Due to the high costs of specialty medications, copay assistance is particularly prevalent—with patients using an estimated $19 billion worth of copay assistance to help pay down their cost share in 2022 alone. While copay assistance is offered by a pharmaceutical manufacturer or charitable organization, specialty pharmacies often help provide support in coordinating assistance for these high-cost medications. In addition to helping secure and facilitate copay assistance for eligible members, specialty pharmacies help navigate complexities such as manufacturer restrictions and program variability.

Why is navigating copay assistance challenging for patients?

Without the proper support and education, patients may not even realize that copay assistance exists. If they are aware of programs, they are solely responsible for initiating copay assistance and following up on any potential rejections, which leads to disproportionate time spent understanding the ins and outs of the programs. Frequent program changes and eligibility requirements can lead to confusion and errors on the part of the patient, and there are limitations placed on third parties helping patients directly with copay assistance.

Copay assistance adds another layer to an already intricate billing process, and a variety of billing methods utilized by copay assistance programs further increases complexity. Manufacturers may issue one-time debit or credit cards to patients, or change their benefits year over year. Foundational support often lacks transparency, sharing limited information about funding pools and which diseases they support. All of this can lead to patients feeling overwhelmed, and cause them to miss out on vital financial aid.

What an ideal specialty pharmacy support model for copay assistance looks like

Copay assistance can be opaque and confusing, and a good specialty pharmacy provides clarity and guidance for every stage of the member’s financial journey.

Ideally, the specialty pharmacy will track and maintain real time copay assistance programs available for specialty medications. This information sets the foundation for the pharmacy to proactively offer and enroll eligible members in copay assistance or provide available copay assistance options to a member who expresses a financial hardship. 

Where applicable, the pharmacy will take all the necessary enrollment steps on behalf of the member to maintain a seamless experience. Where self-enrollment is required, the pharmacy offers education and self-service feedback loops to support the member’s enrollment journey.

Next, the specialty pharmacy will help set up the member’s account, automating the process when possible, and providing accurate information at multiple touchpoints. With enhanced reporting, manual interventions can help members facing rejections.

For billing, the specialty pharmacy will submit claims and resolve all rejections in a timely manner. Clear communication at this juncture is key, with up-to-date notifications of program changes, real-time visibility on eligibility and pathways for issue resolution.

Finally, when a copay assistance cycle ends, the specialty pharmacy will proactively seek re-enrollment opportunities, either with the same program or another applicable one. Call, text and letter campaigns can be used to help members re-enroll with manufacturers or foundations. Throughout the copay assistance journey, the specialty pharmacy will provide benefit clarity to the member, and make sure the process is as seamless as possible.

The importance of operational agility in a specialty pharmacy partner

A good specialty pharmacy partner should be able to provide the following capabilities:

• Copay assistance billing - There are multiple ways to bill copay assistance programs and these guidelines are set by the manufacturer of the program. Billing can be a lengthy process, and finding technology-driven solutions that reduce the amount of time it takes to successfully complete a copay assistance billing cycle is important. With these solutions, a specialty pharmacy provides members with real-time visibility to cost shares and balances in several settings whether the member is on the phone, utilizing digital capabilities or receiving invoices with their specialty medication orders.
• Customer preferences - Just as digital preferences continue to evolve in everyday lives, they also continue to evolve in specialty pharmacy. While some members prefer a hands-on experience, there are others that prefer to have options like self-service features, including an online entry portal to provide copay assistance details that will auto-populate directly into a member’s account.
• Prescriber engagement - Other stakeholders play a role in the member’s financial journey. It is a common practice for a prescriber to provide information to the pharmacy to start the copay assistance enrollment process and a good specialty pharmacy will be focused on providing capabilities to hubs and prescribers that ease the ability to share this information based on their preferences.

As the specialty copay assistance landscape continues to evolve and change, it’s imperative that a good specialty pharmacy partner adapt to ensure patients have a seamless experience. At Accredo, we have the resources and capabilities to deliver technology-driven solutions to provide better experiences for our stakeholders.