Many drug manufacturers offer copay cards to commercially insured consumers, which reduce the member’s personal out-of-pocket expense for the drug while frequently driving utilization to high-cost, branded specialty drugs. These cards are made available to all members, unlike needs-based cards that are used only by members with documented financial hardship.
Previously, third-party dollars available through these copay cards have been used to fund the members’ deductibles and/or out-of-pocket maximums (MOOP). As a result, the member meets his or her deductible and/or MOOP more quickly, and the health plan or group ends up paying sooner than it should.
To prevent situations like this, as of Oct. 1, 2017, we will institute a Specialty Copay Card program. Members can still benefit from their copay card, but the dollar amount paid by the drug manufacturer will not be used to lower their deductible and/or MOOP. Only the amount actually paid out of pocket will go toward lowering the member’s deductible and/or MOOP.
Who is impacted by the program?
BlueChoice HealthPlan CarolinaADVANTAGE and large groups will be impacted on Oct. 1.
Can members still use manufacturer copay cards?
Yes. Members will still receive the benefit of the coupon in reducing their personal cost for the drug. Only the administration of the benefit surrounding the use of the cards has changed. Copay cards for drugs in a retail setting are not included in this initiative.
How are members’ accumulators impacted under the program?
The full value of the copay card toward a particular prescription initially comes over and reduces the member’s deductible and/or out-of-pocket (OOP) accumulators. Caremark sends an adjustment within 24–48 hours to remove any dollars the member did not actually fund. Only the amount actually paid by the member is applied toward the deductible and OOP max.
What drugs are included?
All specialty drugs dispensed via CVS/specialty that offer a non-needs-based copay card. This includes the large majority of specialty drugs.
Communications
We will send this communication to impacted groups.
We will send letters in early August, to all impacted members who are currently having prescriptions filled for specialty drugs through CVS/specialty.
Please contact your BlueChoice® representative if you have any questions.