Updated Dynamics of Assistance Vendors

Patient assistance dollars from Pharma exploded in recent years as companies worked to get patients on their medications and use this funding as a political talking point for patient access. Patient assistance programs claim to lower costs for patients and increase medication adherence. As vendors popped up with the promise to help plan sponsors access these dollars, Pharma responded. In addition, the federal government recently signaled their ability to end the practice of plans accessing these dollars.

As a not-for-profit purchasing cooperative owned and governed by our members, National CooperativeRx has spent a lot of time assessing this marketplace dynamic. To capture value, a few members have engaged with assistance vendors, a few have left the Cooperative to fully engage assistance vendors, while more have implemented PrudentRx or True Accumulations, offered by CVS Health®. When analyzing one of these assistance vendor setups, there are important aspects for plan sponsors to consider, especially given new developments on the matter.

In a prior post, the Cooperative advised members and partners to check with legal, check the math, and read the contract. Accessing these dollars is a complicated dynamic. Check with legal to maximize the chance the plan avoids tax and discriminatory pitfalls. Check the math to ensure the alternative funding vendor is factoring in fees, current and future rebate values, and future changes in the generic and biosimilar marketplace. If you do not check the math, the vendor’s spreadsheet may offer a scenario very different than future impacts to drug costs. And finally, read the contract as it outlines how fees are calculated, what degree of transparency may or may not be provided, and how a plan can terminate a contract if promises are not met or the marketplace changes.

Like many things in the prescription drug marketplace, the alternative funding space has changed rapidly and continues to do so. Pharma has been acting as the value of the programs they designed to circumvent pharmacy benefit manager (PBM) formulary and tier strategies have gotten out of their control and now erode their bottom lines and profitability.

AbbVie

The maker of Humira, the number one selling drug for many years, AbbVie, changed assistance dynamics with several actions. One, AbbVie reduced available value, put controls in place to make it harder for plan sponsors to push patients off on patient assistance programs, and called out specific alternative funding vendors by name as not eligible for their need-based and/or non-needs-based assistance programs. Second, AbbVie sued alternative funding vendor Payor Matrix in May of 2023, alleging ‘fraudulent and deceptive scheme’ to maneuver ineligible patients in AbbVie’s patient assistance program. This lawsuit is ongoing. Third, AbbVie sent letters to patients and industry executives discouraging them from working with SHARx, another alternative funding vendor. Finally, as utilization of Humira has dropped with the introduction of lower cost biosimilar competition, the alternative funding value of these fills is dramatically reduced.

State Legislative Activity

PBMs have responded to the coupon dynamics of Pharma by introducing copay accumulator and maximizer programs. An accumulator program makes sure coupon value is not counted towards deductibles and/or out-of-pocket maximum limits. A maximizer or variable copay program makes sure the full allowance of coupon value is extracted, with anything over and above the patient cost share coming back to the plan sponsor to offset the value of the medication. Many states have come down on this offering and placed bans in the fully-insured marketplace, where they have jurisdiction. While the limits do not apply to private-sector plans, public self-insured plans are impacted.

U.S. Labor Department

The U.S. Labor Department sent a message they may soon come down on self-funded health plans who send specialty drug patients to charities to pay for the drugs. Lisa Gomez, the head of the Employee Benefits Security Administration testified on June 27, 2024, that the department has the statutory authority to stop the practice. Along with the general practice, Ms. Gomez raised issue with the marketing practices used by the vendors, stating the programs are often not what plans thought they signed up for.

Vendor Pivot

As Pharma has made it harder for vendors to access funding and patient assistance funding has diminished, alternative funding vendors have had to pivot to show value in other ways. We know value has diminished not only due to the points above, but because we have seen the savings numbers from PrudentRx begin to diminish over time and expect that trend to continue as these strategies run their course.

The Cooperative has seen shifts in vendors’ savings calculation methodologies, the expansion of program portfolios to include more products, and the leveraging of multiple sourcing options. One way vendors are attempting to show additional value is through international sourcing. Not only has the Cooperative proven significant limitations to international sourcing value, but there continues to be risk and legal issues. In our calculations, the risk outweighs the potential benefit.

Assistance programs fill an important role in providing prescription drugs to the uninsured, underinsured, and individuals who cannot afford their cost share. These programs have gone much further than originally designed. Complexities in the prescription drug industry have allowed new vendors to arrive and benefit from these dynamics. Pharma and the federal government have begun to reduce the value and signal limits to these practices. To offer a sustainable benefits package to employees, be even more diligent in your assessment of these vendors. If you have questions about a comparison being ‘apples to apples,’ National CooperativeRx is here to help.