A common challenge for specialty and specialty-lite brand commercialization teams is maximizing prescription coverage while minimizing free goods program overutilization. Patient bridge and quickstart programs, which provide temporary access to medications for patients experiencing coverage gaps or delays, are essential for therapy continuity and preventing financial burden on patients. However, these programs can negatively impact the manufacturers’ bottom line if manufacturers don’t implement the appropriate safeguards and requirements. At their core, these programs should be a tool to buy time for coverage and not a primary funding source for patient medications and pharmacies.
Manufacturers should analyze their program design and consider the subsequent financial implications to ensure that they are effectively promoting patient access while managing their gross-to-net (GTN) performance to sustain the long-term viability of their branded therapies. Brand teams can use several approaches to optimize their bridge or quickstart programs:
Most specialty and specialty-lite pharmaceutical manufacturers invest in various financial support programs to support continuity of care. With as many as 70% of patients on newly-launched specialty drugs using a patient assistance program subsidized by the manufacturer, commercialization teams must manage these programs the most of these programs effectively.
When patients are unable to get their prescription covered due to an expired prior authorization (PA), lack of formulary placement or change in insurance coverage, a manufacturer-sponsored bridge or quickstart program provides a lifeline to patients to help them get started on a therapy that can improve their quality of life. Not only does this have benefits for speed to therapy, but it also has positive implications to brand loyalty amongst HCPs that can feel confident that patients can adhere to their intended care plan. Manufacturers rightfully view these programs as part of their commitment to patient care and access. Yet, if the program is not designed effectively (i.e. no requirement for a prior authorization submission for eligibility), a bridge program can impact the brand's GTN and bottom line as follows:
Increased buy downs: When a manufacturer has to buy down more prescriptions that get covered by insurers, they can significantly impact a manufacturers net revenue. These “rebates” are deductions from the list price, affecting the overall net revenue and profitability.
Higher hub or pharmacy fees: Implementing and administering patient bridge programs can incur additional operating costs, including program management, customer support, enrollment processes, and coordination with specialty pharmacies or distribution channels. These expenses can significantly impact the bottom line with overutilization particularly if the partner is utilizing an FTE staffing model.
Deferred revenue: Relying on a bridge program for an extended period may delay a patient's transition to full insurance coverage or alternative support programs. As a result, manufacturers experience prolonged periods of reduced or delayed revenue until patients secure proper coverage, diminishing cash flow and profitability. This can have significant implications on a brands ability to invest in growth to serve more patients.
Pharmacies can significantly impact pharmaceutical manufacturers' commercial success as crucial players in the prescription fulfillment process. A pharmacy network's contractual agreements and affiliations with payers, PBMs, and PSAOs can greatly influence coverage. A fragmented dispensing network diminishes a manufacturer's ability to deliver to patients and can hurt the bottom line by over-relying on free goods programs to fill coverage gaps. Many pharmacies that utilize mail order models are increasingly relying on manufacturer sponsored bridge programs as a key revenue stream when brands face significant obstacles to secure coverage as it presents an easy, less expensive path to revenue. Therefore, it is imperative to ensure your network has not only the contracts to deliver effectively and allows manufacturers to have tight control over the business rules surrounding their free goods programs.
Stringing together your own network of pharmacies or specialty pharmacy partners is risky, operationally challenging, and often proves to be a costly mistake as the ability to be able to monitor them and make adjustments to business rules can be overwhelming. Without tight integration, you are likely to experience the same challenges with free goods overutilization. Working with a commercialization partner that integrates a robust and varied national network of pharmacies into its solution is ideal for maximizing plan contract coverage while minimizing bridge plan utilization.
Check out this eBook for a deeper dive into how to optimize prescription coverage at the pharmacy.
If your brand faces significant generic competition or is going to market with a significant list price, you are almost certain to face utilization management obstacles. The PA process is prone to errors and challenges, such as changing payer rules, lack of transparency, and the use of multiple utilization management measures, which can create gaps in coverage. However, brands must accept this and take a proactive approach to ensuring they have the right partner to facilitate submissions as well as structure their free goods program design to ensure that the only means to access it is if a prior authorization is submitted by the HCP.
Brands should note that while many retail & specialty pharmacies assist with the PA process, most leave it up to the prescriber or patient. In many cases, pharmacists and pharmacy techs manually process PA requests, which is time-consuming and delays therapy initiation. While this is an ideal time for a quickstart program, it’s often difficult for manufacturers to implement business rules to deliver a parallel dispense approach effectively..
The key to getting (and keeping) patients off free goods programs and maximizing coverage is to implement a data-driven approach that streamlines the process from start to finish:
Employing user-friendly technology to simplify enrollment & BV processes
Educating patients and healthcare providers on alternative patient assistance programs
Using feedback loops to stay on top of evolving payer prior authorization requirements
Utilizing data that differentiates dispense workflows based on payer behavior
Providing full visibility into the prior authorization journey
Maximizing prescription coverage for branded therapies while minimizing reliance on patient free goods programs is a complex but crucial goal for pharmaceutical manufacturers. By understanding the gross-to-net effect of your program, partnering with a robust network of pharmacies, and modernizing your PA process, you can enhance coverage and ensure that patients have uninterrupted access to your prescription therapy.
With Phil, you can access a nationwide pharmacy composed of retail, chain, and specialty pharmacies with 98% plan coverage. The data-driven PhilRx platform gives you complete control over your financial assistance programs – supporting patients as intended while protecting your margins – and serves as a digital front door for all your patient services.
Get started by requesting a consultation today!
Our consultants will work with you to analyze your current channel strategy and make recommendations for how to improve patient access and increase the percentage of scripts getting covered by insurance.