Copay Offset Program

Program Objectives

Our program has been developed to allow self-funded employers the opportunity to save substantial costs by utilizing our unique approach

By utilizing the willingness of drug manufacturers to support patient copays we can lower the total cost to the self-funded employer

Our mission is to provide employers with a service that educates and informs patients of the high cost of specialty drugs and allows for maintaining substantial benefits into the future

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Keys to understanding the service offering

Drug manufacturers understand that high deductible plans are growing in number.

Patients co-share can be as high as 20% of the drug cost

The financial reality for the manufacturer, is that 80% of the reimbursement is still acceptable to them. Therefore, they are willing to underwrite up to 20% to capture and retain patients

The competition in each category is growing and no manufacturer will be the first to pull this support.

Over the last 5 years these support programs have grown even more numerous and generous

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Employer Opportunities

Employers that have a minimal cost sharing program in effect have the most to gain

Employers that utilize a PBM that has a shared accumulator with the medical benefit are best suited to program

Union Employers can benefit because there is no reduction in benefit. In fact often times the copay can be reduced to $0 using the program

No size limit to employer, every employer can benefit

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Program DetailsDrugs Covered

These drugs represent over 50% of the specialty spend on the pharmacy benefit

Aubagio Avonex Benlysta BetaseronCimzia Copaxone Enbrel Extavia Gilenya Harvoni Humira IlarisOrenciaOtezlaPlegridy PenRebif Simponi Aria Sovaldi Stelara Tecfidera Viekira PakXeljanz

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Program Details Benefit Design

Where appropriate the PBM sets the level of copay for the listed drugs at the individual max of $6,600 and family max of $13,200 (subject to change)

If a shared accumulator is not being utilized a split may need to occur between the two benefits

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Program Details Employer and Employee Communications

Communication is the key to execution success

Our Team works with the employer to educate the employees on the program and explain why this is an important part of the company’s ability to manage costs.

We work with HR to create communication tools to ensure no employee is ever disadvantaged due to the program

During the implementation timeframe our Team reaches out to all employees to educate them on the program and to enroll them in the manufacturer program

Employer and employee have a single contact number to assist with the program to ensure no gaps exist

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Program DetailsExisting Patients

Patient Identified

Program team

reaches out to educate

patient

Program explained

and patient ops into co

pay program

Service team

notifies pharmacy

of secondary

billing number

Patient Receives drug with no or little

copay

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Program DetailsNewPatients

Patient receives script for

listed drugPharmacy

adjudicates claim and sees that

there is an administrativ

e PA

Pharmacy calls service center and

indicates the patient name

and drug

Service center

educates the pharmacy on the process

and contacts patient

Service center

educates patient and enrolls them in the copay program of

manufacturer

Service center notifies

pharmacy and provides

the secondary

billing information

Patient is contacted by pharmacy for

shipment information

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Service Center Billing Requirements

Service center requires access to PBM data directory or through association to reconcile savings with employer

Savings are calculated based on enrollment information

A percentage of savings is paid to service center as program fees

If employer does not save money then there is no cost to the employer

Fees are available to associations or brokers for implementation and assistance throughout program

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Our Team

Our team is made up of experienced specialty pharmacy and call center experts

The leadership team has built many custom service offerings for employers, major insurers, grocery chains and university health systems

Team has deep understanding of the PBM and Specialty Industry, consulting across all drug delivery channels

Our call center technology is the latest cloud technology allowing for rapid deployment of additional personnel as needed

Company is based in Buffalo, New York and utilizes trained Pharmacy Techs as support center personnel

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Next Steps

Sign Non Disclosure Statement and Business Associate Agreement

Evaluate opportunity for savings by reviewing PBM Data

Present to Employer savings opportunity and set go live date