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Patient Assistance Programs: A Shield from High Cost or Trampoline for Abuse?

Patient Assistance Programs (PAPs) operated by pharmaceutical manufacturers, nonprofit organizations, and government entities are designed to relieve financial pressures by helping those in need obtain their medications. Currently, there are over 350 programs and companies covering more than 4000 drugs.

Figure 1.

Patient assistance generally comes in 2 forms:

    1. Copayment assistance: These programs help reduce the patient’s OOP responsibility, including coinsurance and deductible support, depending on treatment setting.
Clogged Artery
  1. Replacement drugs: The hospital pharmacy provides the prescription medication to the patient for free, and the drug manufacturer replaces the product back to the provider at no cost.

One of the challenges in securing PAP aid is proactively monitoring changes in patient eligibility and documentation requirements. Most PAPs require an application, yet no 2 programs are the same, and the amount of information required varies.

Tyrone’s Commentary:

Two examples of caution when it comes to PAPs. First, some programs provide assistance for the purchase of high-cost drugs that have no generic equivalents or close therapeutic substitutes. In such cases, assistance programs can expand access to therapies that represent the standard of care but can also promote use among patients who do not place a high value on the health benefits associated with these therapies.

Patient-assistance programs may lead to higher drug prices as a result of the interplay between patient demand and prices. Economic theory predicts that if patient demand becomes less sensitive to prices, manufacturers of on-patent drugs will respond by setting higher prices. Despite these two downsides PAPs have more pros than cons.

Some programs require detailed medical and financial information (see figure 1), and others ask for very little. In addition, although all require a physician’s signature, some programs require the doctor to complete a portion of the form, and others only need a signed prescription.

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Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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