Mapping the Copay Journey in Pharmacy and Medical Benefit Settings

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1 Mapping the Copay Journey in Pharmacy and Medical Benefit Settings Melissa Paige Darrah Seawell 5 th Annual COUPON and COPAY

2 Talking Points Current issues and pain points seen within a large academic center Finding access and managing out-ofpocket barriers to copay assistance programs Understand the process once a patient enrolls in a copay program What s working and what s not from the patient perspective and where improvements could make a big impact Disclaimer: The views and opinions expressed are those of the author and do not necessarily reflect those of UVA.

3 Overcoming Barriers Streamline from Manufacturer to Patient Manufacturer Healthcare Provider Patient

4 Large Academic Center Everyone is trying to help Nurses Everything sent to PA Different Hubs Multiple Clinics Loose Interaction with Billing Department No Follow Up Inconsistent Process Inconsistent Results

5 Large Academic Center Challenges Right; Drug, Patient, Time OOP Documentation Procurement Billing Claims Payment Misc Codes Revenue Cycle Patient Physician Nurse Coordinators Financial Counselor Patient Assistance/ Advocate Pharmacy Infusion Pharmacy

6 Large Academic Center Where should Coupon & Copay Live Close Interaction Pharmacy Financial Coordinators/Billing Not Clinic Nurses

7 Coupon & Copay Some resistance from HCP Time Consuming for HCP s Manual Process Portals NPI vs Facility Tax ID Multiple Notifications Payment to Account

8 Finding Access Three Clicks or Less Website Navigation FRM Training How to get Coupon or Copay Assistance Enroll - Portal PDF - Fax How to use the benefits How to get a claim paid Either on Medical or Pharmacy Benefits

9 Coupon & Copay Pharmacy vs. Medical Benefits All Infusion Product Copay Programs need Pharmacy Billing Info Medical Billing Info Some Infusion Brands Copay Assistance is not set up to be utilized through pharmacy benefits

10 Coupon & Copay Pharmacy Benefit Pain Points Patient exhausting Insurance Max Benefits Patient exhausting Copay Card Max Benefits Day 31

11 Case Study 1 Pharmacy Benefit Copay Assistance Expensive Specialty Drug High patient out-of-pocket copay Copay card approved Insurance max benefits reached Copay max benefits reached Now patient has to pay full price for all other Rx Total Care of the Patient

12 Coupon & Copay Medical Benefit Reimbursement Reimbursement Bundled Payments Have a process to still be able to pay on these claims Pt starts treatment based on Copay Assistance Submission Portals 95% claims rejected when faxed. (Not legible) 95% claims approved when uploaded the first time. Challenges Faxed Claim Need Notification When received Approved or Denied

13 Coupon & Copay Medical Benefit Pain Points Marketing Materials Patients given option to receive check or card 3 rd party copay vendors being educated on what to look for J-Code, does not spell out drug name No EOB that we have run across yet that has a J-Code and the drug name on it.

14 Case Study 2 Medical Benefit Copay Assistance Medical Benefits mandating to use Pharmacy Coupon & Copay follow the Medication Impact on Medical Deductible and Yearly Out of pocket Manufacturer having options to help with Infusion costs

15 Working & Not Working Coupon & Copay Programs Working Instant online portal/web enrollment Consistent manufacturer engagement Not Working Required to have physical card before enrollment Manufacturer requires patient to enroll

16 Coupon & Copay Recommendations Manufacturer Representative Meet with Account Oral/Infused Misc. J-code/Revenue Code Bundle Billing Follow-up meeting with HCP Account Pharmacy/Patient Assistance Department Financial Coordinators Billing Department Determine how to fold into existing process

17 Coupon & Copay Recommendations Copay Portal Field Reimbursement Education Beta Test Copay Card Payment to the HCP Portal setup HCP, make easy (list of NPIs)

18 Infusion Re-Verification Re-Verification Make it easy for HCP to re-verify patients Comprehensive list of all patients enrolled Portal FRM Current State Fax Phone

19 Goals Patient Satisfaction Adherence HCP On Treatment Payment

20 Melissa Paige Darrah Seawell To provide excellence, innovation and superlative quality in the care of patients