Reducing Financial Burdens for Patients and Plans
Managing specialty drug spend is at the top of the list of plan sponsor priorities. Although specialty drugs are used by only 2% of the population, specialty drug spend jumped from 44.7% in 2018 to 47.7% in 2019, nearly half of all spending on prescription drugs.
Without specialty management strategies in place, clients risk having budgets overwhelmed by the costs of what may be just a few high-cost treatments, potentially impacting the benefits of all members. It’s a gamble no employer or health plan wants to take, especially as we see more high-cost medications, like gene therapies, in the pipeline in coming years.
Over the past decade, Express Scripts has been monitoring manufacturer programs targeted at getting patients started and staying on certain specialty drugs. Manufacturers invest heavily into these programs, which certainly help patients to stay adherent to medications, but open up the opportunity for members to circumvent payer plan design. In 2016, we identified the opportunity to build and pilot payer copay solutions, which would allow members to leverage this financial support, while also helping to drive down plan spend on high-cost, specialty medications.
By expanding the initial suite of copay solutions and working with SaveOnSP, Express Scripts was able to help create unique savings opportunities that maximize the use of manufacturer assistance funds. In 2020, plans that participated in these copay assistance solutions experienced a specialty trend of negative 7.2%, while nonparticipating plans experienced an 8.7% specialty trend.
Most importantly, 100% of SaveOnSP patients within plans enrolled in the SaveOnSP program have $0 remaining responsibility, even after copay assistance has been exhausted.
What’s “non-essential” about life-saving treatments?
Plans that participate in SaveOnSP classify certain medications as "non-essential health benefits" (NEHBs) in alignment with the Affordable Care Act (ACA). This classification does not speak to how critical a medication is for the member to receive. Both Express Scripts and plan sponsors understand that NEHBs are necessary for members to obtain. However, the ACA only requires coverage of a specific number of medications in each therapy class. Anything beyond that can be classified as NEHB, which does not impact the patient’s ability to access the medication, but does open up the opportunity to maximize copay assistance to benefit the plan and patients.
With SaveOnSP, patients get their NEHB medications for $0 patient responsibility.
Making the most of manufacturers’ funding for copay assistance
While we believe lowering the cost of drugs to increase access for patients is the best thing pharmaceutical manufacturers can do, copay assistance programs remain the preferred choice for drug makers.
The SaveOnSP solution is one way we’re helping patients leverage the financial support of copay assistance while driving down plan spend on high-cost specialty medications.
Through this and other innovative programs, we’re working every day, on behalf of our clients, to unlock value and make health care more simple, affordable and predictable.