What are specialty coupon maximizers?
To answer that question, it’s important to know what a specialty coupon is. When most people think of a specialty coupon, they think of the commercial stating if you cannot afford your prescription, to call the number provided. This is only partially true. There are normally two programs provided by the manufacturer, a patient assistant program, which is income based for uninsured patients, and the manufacture coupon for those with commercial insurance. The coupon helps members by covering their copay or coinsurance up to a certain amount. As specialty medications became more common and more expensive, coupons became more popular. The original purpose of the specialty coupon maximizer programs was to maximize how much of the coupon was used each time the patient filled the medication by creating a variable copay process in which the members cost share changed to closely align with the coupon value, therefore decreasing the plans share of the medication. The programs are normally paired with a true out of pocket program to make sure the coupons were not counting towards member accumulator amounts and members only get credit for their true out of pocket costs.
Coupon Program Concerns and Manufacture Updates
There has been an increase in drug manufacturers such as AbbVie and Johnson & Johnson (J&J) who have informed PBM’s with these programs that they have updated their terms to where the employers are not benefiting from coupons. These drug manufacturers created coupons for members who need financial assistance and not for the financial benefit of employers and PBM’s.
While it seems like the manufacturer is doing something kind for patients, there is a downside of these coupons. Whether driven by the PBM Program or the incentive provided by the manufacturer, members continue to lean towards medications that provide assistance without understanding the high cost the plan is picking up for these medications. There could potentially be less costly drug alternatives for members to utilize versus the more costly drugs that have coupons.
In May 2022, J&J filed a lawsuit against SaveOnSP based on their claim that they have lost over $100 million in revenue due to coupon maximizers.1 They believe that members are being influenced by the PBM’s and pushed to use the more costly drugs that would allow employers to benefit from the coupon savings.
In response to the lawsuit, SaveOnSP advised that the drug manufacturers can change how much they allow for the coupon amounts. J&J does not feel this makes much of a difference to their loss of revenue as they have tried this approach with Tremfya and Stelara to no avail.
As of 11/1/2022, AbbVie has announced they will be making changes to their terms and conditions with co-pay assistance programs.2 Members whose plans are enrolled in the co-pay maximizer programs will no longer be able to use copay assistance coupons. On top of making this update, AbbVie will also be conducting internal audits to identify the members who will be impacted by this change to their terms and conditions.
A few of the drugs that will be impacted by this update are Humira, Skryrizi, Rinvoq, and Xeljanz. As of February 1st, the big 3 have started to phase out AbbVie and J&J medications from their maximizer programs.
What’s next for the Copay Coupon?
While we believe that these programs still provide must need relief for plan sponsors, we have warned multiple times that these programs are not sustainable in the long term. They are a double-edged sword. The more patients maxing out the assistance, the more the manufacturer loses in their revenue, so they combat it by increasing the cost of the medication. But plans without the program don’t get a discount in the cost of the medication if they don’t enroll in the programs.
We believe that if AbbVie and J&J are successful at fighting these programs without impact to their sales, it is likely that other manufacturers will follow quickly, which would likely end these programs as we know them today, at least for specialty medications.
If you have questions about the current state of specialty coupon maximizers, contact our pharmacy practice.
- “SaveOnSP Program and Other Co-pay Maximizers” FrierLevitt, accessed February 02, 2023, SaveOnSP Program and Other Co-pay Maximizers Costing Manufacturers, Patients, and Plan Sponsors More (frierlevitt.com)
- AbbVie News, accessed February 02, 2023, https://news.abbvie.com/