Prescription drugs are often a vital part of a person's daily health regimen, but the cost of treatment can be a barrier for some. In fact, data from a Kaiser Family Foundation poll shows a quarter say they have a hard time affording their medication. In the same survey, 31% of respondents said cost prevented them from keeping their regiment, and either skipped filling a prescription, took an over the counter instead, or altered a dose. When patients are unable to take their medicines as prescribed, it is a significant and contributor to overall U.S. health care costs.
Many chronic conditions are treated with biologics—complex molecules made from living cells—making them expensive to produce. These are often created and marketed under a single brand-name or specialty drug manufacturer. In one analysis, researchers shared that specialty drugs have higher list prices in the U.S. than in Switzerland and the United Kingdom. While generic drugs comprise most prescription fills, research shows specialty drugs represented 54% of total drug spend in 2023, even though drug price growth, overall, has slowed.
Manufacturers may offer copay assistance coupons to patients who use these medications to help offset the cost of them. These assistance programs are intended to help limit patients' out-of-pocket costs in two ways. First, they reduce the amount a patient pays at the pharmacy counter when they fill their prescription. Second, the value of the coupon may also be applied to a patient's annual cost-sharing requirement, like deductibles.
Pharmacy benefit managers (PBMs) and insurance companies offer various tools to encourage patients to choose lower cost drug options. Some health plans restrict the use of copay coupons toward deductibles by implementing copay adjustment programs. When a patient's health plan uses a copay adjustment program, sometimes knows as copay accumulator or maximizer programs, it restricts a manufacturer's assistance coupon from counting toward a patient's annual out-of-pocket maximums. When the value of the coupon is exhausted at the pharmacy counter, the patient must cover the full amount of his or her annual cost-sharing requirement before plan benefits kick in.
Although copay adjustment programs might encourage patients to look for cheaper alternatives before turning to a more expensive treatment option, they can be problematic for individuals whose plans involve high cost-sharing or co-insurance—where a patient pays a percentage of the cost rather than a flat amount. Moreover, people with complex conditions, such as cancer, rheumatoid arthritis and diabetes, requiring expensive prescription drugs may have few alternatives.
One study found that copay assistance may have the potential to narrow disparities for Black/African American or Hispanic patients taking RA medicines, and patients with household incomes less than $50,000, from abandoning their prescriptions due to cost.