[Updated] Ep. 69 | How to Navigate Upcoming Copay Assistance Program Changes

[Update October 3, 2018] Join us this week as we revisit another of our most popular recent episodes. This episode features an in-depth chat with Nicole Felty, Specialty Operations Manager at CSI Specialty Group. Listen in as we chat with her about what it takes to overcome the complexities of copay assistance program changes.

[BONUS RESOURCE] Also, check out the latest video from the National Hemophilia Foundation on how co-pay accumulators work. It demonstrates how Copay accumulator adjustments affect patients requiring specialty medications with no generic alternatives.

“The Only Thing That Is Constant Is Change.” – Heraclitus

In this episode, we welcome resident reimbursement expert and Specialty Operations Manager at CSI Specialty Group Nicole “Nicky” Felty to discuss how to navigate upcoming copay assistance program changes, what they mean for your pharmacy and how they will impact your patients.

Nicky joins host Suzette DiMascio, CHE, CMCE, CPC, to share can’t-miss tips, examples and keys for success in this 16-minute interview.

Tune in to Discover:

  • Changes coming to copay assistance programs and how they will affect patients (and your business)
  • The importance of copay cards and how they work
  • A status update on what plans are eligible for copay assistance
  • How the average patient can navigate insurance copays to minimize out-of-pocket expense
  • Who to call at health plans to get the answers you need if there’s a copay issue

About Nicky Felty

Nicole “Nicky” Felty’s 25 years of industry experience span multiple healthcare channels including United Healthcare, Humana Military, and Priority Healthcare. Prior to joining CSI Specialty Group, Nicky was part of the team that founded and launched Prime Specialty.

About CSI Specialty Group

CSI Specialty Group is a globally recognized leadership, strategy and talent consulting firm dedicated to helping clients drive sustainable, accelerated growth while continually elevating the specialty pharmacy industry. By providing inventive specialty pharmacy consulting, workforce planning and talent acquisition solutions, CSI uniquely tailors its service offerings to help clients drive sustainable, accelerated growth. As the provider of the industry’s first, dedicated podcast for specialty pharmacy, CSI is at the forefront of pioneering innovative concepts to meet the changing needs of specialty pharmacy, home infusion, mail order/PBM, health systems and pharma/biotech clients across the USA and throughout Europe.

Transcript Notes:

Suzette D.: Hi. This is Suzette DiMascio with the CSI Specialty Group Podcast, and today, I’m really excited to introduce a new member to the CSI family, Nicole Felty. Good morning, Nicole.

Nicole Felty: Good morning, Suzette. How are you?

Suzette D.: I’m doing great, doing great. For our audience to get to know Nicole a little bit better, I have to tell you we’re just thrilled, Nicole, to have you join our team. You’ve got such a stellar background in the reimbursement world, and I’m going to brag about you for a couple minutes if that’s okay.

Nicole Felty: That would be fine, and please call me Nicky.

Suzette D.: Okay, Nicky, fantastic. Nicole actually has quite a stellar background in reimbursement in payor strategy. She’s actually worked for a lot of different channels in the healthcare space from United to Humana Military to an employee trust, was part of the Priority gang that from all good things have come in specialty, correct, Nicky?

Nicole Felty: That is correct. Yes.

Suzette D.: And most recently was part of the startup team at Prime Therapeutics, so we’re happy you decided to come to the dark side on the consulting area.

Nicole Felty: Well, thank you for having me. I’m excited to be here.

Suzette D.: Thanks. Nicky, one of the things that our clients have really enjoyed spending time with you is really getting an understanding about the whole reimbursement world, and one of the things that you and I and the rest of the team have been hearing a lot of questions about and have been in the media is about copay cards and challenges and benefits and so forth. So, I wanted to take this time and learn, help you educate our listeners, and considering there may be some patients on listening as well, let’s just kind of start from the basics. Can you kind of tell us a little bit about from your perspective how you envision the importance of copay cards, and basically what they are, and who issues them and why?

Nicole Felty: Okay. Well, copay cards are out there for assistance to help members with their out-of-pocket expenses for those high cost medications. As most people are aware with how the insurance companies’ benefits are, they may have a high deductible plan, so the copay cards are issued by manufacturers in order to help with those high out-of-pocket expenses.

Suzette D.: Now, most of our listeners know this, but for those that don’t, there are some people that do not qualify to receive this extra assistance.

Nicole Felty: That is correct. If a member happens to have any insurance under a federal, state, or government funded insurance plan, they’re not eligible so that would mean your Medicare, your Medicaid, TRICARE, Department of Defense, or any Veteran Affairs program. They are prohibited by law, and there are a few other states that it may be prohibited.

Suzette D.: Now, how does this differ from financial assistance through a different fund? Is it the same requirements?

Nicole Felty: Every requirement’s different. Each program has their own requirements. Most of the time for our copay cards through the manufacturers, they do not have income restrictions. More so, your income restrictions are found with your foundations, which are all donation-based programs.

Suzette D.: Got you. Got you. And for those of you that are listening, there are a lot of foundations today, since it’s January going into February, that have got a lot of funding available. So, it’s important as we’ve heard from one of our guests, Jennifer, on last podcast, or excuse me, the podcast at the beginning of this year, talk a little bit about the importance of knowing your therapeutic area and getting involved in the foundations quickly, so they can help you with some of your financial assistance.

Suzette D.: So, let’s talk a little bit more about the copay card and about accumulators. Tell me a little bit about how if I needed to purchase a medicine, and it had a high rate, and I wanted to work with a copay card, for example. Kind of just give us a scenario of how that works.

Nicole Felty: Okay. Well, what I’ll do is I’ll use the same example of one person using a copay card and one not. So, the first example I’m going to use is Jane has a medication that she needs to obtain, and after it’s processed through her primary insurance, her out-of-pocket expense would come back as let’s say $500. Jane pays that $500 to the pharmacy, and that $500 goes towards her insurance accumulators, whether it be her deductible and/or out-of-pocket expense.

Nicole Felty: Now, in the same example, we’re going to have Jane using a copay card. The insurance is processed, and it comes back as that same $500. But she presents a copay card, leaving her out-of-pocket as $5, meaning that the copay company is going to be paying $495, and Jane pays $500 to the pharmacy. The $500 out-of-pocket expense would still go towards Jane’s accumulators, yet she only physically paid $5 out of her pocket.

Suzette D.: Well, that doesn’t seem fair in one way, but I understand the logic behind it.

Nicole Felty: That is correct, and that’s where we’re seeing a lot of changes coming through with these copay cards and accumulators.

Suzette D.: So, it’s interesting because this is almost like the same dilemma that we’re seeing with DIR fees when patients are being charged towards their donut hole in Medicare. But yet, if there’s a clawback on the fees to the pharmacy, the patient’s accumulator doesn’t get adjusted.

Nicole Felty: Correct.

Suzette D.: Wow. Wow. Well, that doesn’t seem right.

Nicole Felty: I understand, but at the same time, the insurance company is looking at what the member’s actually paying.

Suzette D.: That’s true. That’s true. It’s a challenge, but it has to be mitigated with the high cost of these products as well, so I totally get it.

Suzette D.: So, what do I hear about members that have coverage through in the health insurance market that’s called a metallic plan? And I’ve heard that they’re not able to use copay cards, so maybe give us, give the audience a little overview about what a metallic plan is because that’s a new term. It was new to me, and thanks to you being part of our team, I have learned more about it. So, let’s talk a little bit more about that.

Nicole Felty: Well, under the Affordable Care Act, each health insurance plan’s assigned a different metallic level. Those levels are being bronze, silver, gold, or platinum, and those levels are actually what the plan’s actuarially value, an AV level, is on how your plan pays the co-insurance and your deductible. So, for example, your bronze plans, you may have lower out-of-pocket premiums, but you’re also going to have higher deductibles and co-insurance. Where with your platinum plans, you’re going to have higher premiums, but you’re going to have less out-of-pocket expenses as far as your deductibles and your co-insurance levels.

Suzette D.: So, it’s no different than any standard plan, it’s just how they’re determining it differently. But what happened? There’s something that I remember seeing in the media in the middle of last year, about the deductibles. Some things were changing with accumulators. Did that also relate to the medical, these, excuse me, listeners, these new terminologies? The metallic plans. Was it something is it related to metallic plans, or was it for accumulators, in general? Because it did hit the media quite a lot.

Nicole Felty: What we’ve noticed right now is with the metallic plans, this is what we have noticed. So, around July 1st of 2017, we noticed a lot of the insurance companies that had these metallic plans were not allowing the copay cards, that money, to go towards the accumulators. So, if I may, I’m going to use that same example that I used earlier. In which case, Jane goes ahead, has let’s say a silver metallic plan, goes to her pharmacy. She still has that same $500 out-of-pocket expense. She pays her $500. That full amount does go towards her accumulators, being deductible and co-insurance.

Nicole Felty: But now, we’re going to throw that copay card back into the mix. $500 out-of-pocket expense, Jane presents her copay card. The copay card’s going to pay that $495, leaving Jane with an out-of-pocket expense of only $5. That $5, as of right now, potentially is going towards her out-of-pocket accumulators. You may also be asking, “Do all insurances allow this?” That depends on each insurance plan. Some are allowing those $5 to go to the accumulators. Some are not, but if you notice, that $495 that Jane was not paying, those are not going towards her accumulators. So, it’s a big, big uproar right now within the insurance plans.

Suzette D.: So, how does a specialty pharmacy, for our listeners that are helping the reimbursement journey with patients, how do they best help navigate these waters? Who? I guess I’m kind of at a loss for words because this is not something the typical individual understands. It’s for someone that clearly has been in the healthcare industry like you have for many years to understand how to navigate, and a lot of our listeners that are running specialty pharmacies as well. But how do they educate and mitigate risk for patients so that they optimize the minimum amount of out-of-pocket?

Nicole Felty: Well, what we found out is most specialty pharmacies are not even aware of this happening until they go ahead and process that member’s copay card. It’s the next bill being that next month or that next 90 days that we’re finding this out, and what I mean by that is a lot of these pharmacy benefit managers have been just putting in what’s called dual adjudication. So, that’s how they’re finding out that these members are using copay cards, and also that they’re not paying that full out-of-pocket expense. So, what I would suggest for pharmacies to do if they do come across this is have that member reach out to their copay assistance plan, so that way in turn, they can find out a little bit more about how they can still potentially help them.

Suzette D.: Got you. Got you. And so, going back to your days at Priority and Prime Therapeutics, how much time did the reimbursement teams that you worked with spend this time a year trying to just make sense of all this nonsense?

Nicole Felty: Again, with this just going in in July of 2017, and a lot of plans not having their open enrollment and benefit year starting, it’s going to be very time consuming this time of year because this is where you’re going to see January those high deductibles. And next month, this is where members are going to notice that they still owe that extremely high out-of-pocket.

Suzette D.: So, this is going to really affect patients in February.

Nicole Felty: February is when I would suggest, yes, that we will see that.

Suzette D.: Okay. Okay. Well, no. This is a great resource, and part of the reason that I wanted to have you on here was to be able to just kind of give everybody a heads up that the winds of change may be coming in the next two weeks to four weeks, and there’s got to be opportunity for, especially pharmacies, to just have some extra hands on deck to hand held, excuse me, to hand hold not hand held. Excuse the grammar there. That’s what happens when you do these on a morning. To hand hold the members or the patients and get them through the process.

Suzette D.: So, this brings up another question. In your humble opinion, how … I would expect the specialty pharmacy reimbursement teams to understand this a little bit more than the member service hotline at a health insurance plan.

Nicole Felty: Well, a lot of specialty pharmacies do have access to reach a reimbursement specialist within that specialty pharmacy, so I would definitely suggest that the members reach out to the pharmacy itself and ask to speak to somebody with a little bit more knowledge of this.

Suzette D.: Perfect. Perfect. But if they do call their health plan to get some sort of an understanding of what’s happening, and many of them will have to because they’ll be referred to do that from the specialty pharmacy, who is the best person in a health plan for them to ask for that will understand and be able to better solve this mystery for them?

Nicole Felty: It would-

Suzette D.: Because I think that’s important to know that contact person.

Nicole Felty: I would suggest probably a leader or supervisor who would have a little bit more information about that.

Suzette D.: What department?

Nicole Felty: Some-

Suzette D.: What department though?

Nicole Felty: A lot of insurance plans are going to actually refer you to the pharmacy benefit manager directly.

Suzette D.: Okay. Okay. And in that PBM arena, is there a team that is better suited at answering these questions? I’m just trying to drill down the right department so that we can give patients that are listening an opportunity.

Nicole Felty: That unfortunately I do not know off the top of my head only because coming from a pharmacy, we always spoke to the provider line directly, so we didn’t have any direct contact with the member service line.

Suzette D.: Got you. Got you. Got you. Okay. Perfect. Perfect. No, that makes sense. Well, I think that again if people have an opportunity to learn a little bit more about who the right person to call and know that they don’t necessarily need to take, “No,” as an answer the first time, that helps them be involved.

Suzette D.: Can I also give our listeners your phone number, so if there’s any questions that come into play, if we have any patients that are listening, can they just call the CSI office and talk to you?

Nicole Felty: Yes. I would be more than happy to try to assist them with any questions they may have.

Suzette D.: Perfect. Perfect. And so, one more quick question for you. Is there anything else in the financial arena or the horizon that you’re seeing happening this year that could affect our patients, or is this really the big bubble right now?

Nicole Felty: This really is the big bubble, and because it’s so new, we haven’t seen the true impact of this yet. But I’m sure once it starts happening to more and more members, the manufacturers may start getting involved with this, also, and bringing that to the insurance companies’ attentions, too.

Suzette D.: Perfect. Perfect. Well, Nicky, thank you so very much for your time and your insight, and I just can’t tell you how glad that we are to have you on the team. You’ve just been such a valuable resource to all our clients and assisting them not just with issues as it pertains to financial assistance and copays but figuring out a lot of the challenges for payor access and PBM network contracts and everything else.

Suzette D.: So, thank you so much, and as always, this is Suzette DiMascio. If we can be of assistance to you in any way, any questions on the specialty horizon that you need, we’re always a phone call away and appreciate the opportunity to serve you.

Suzette D.: Thanks, Nicky.

Nicole Felty: Thank you.

Suzette D.: Bye.

Suzette D.: Hi. This is Suzette DiMascio, the President and Founder of CSI Specialty Group. Do you want to build the ultimate specialty pharmacy sales team? You can now with the help of CSI University’s online sales training. Built from the ground floor up to help unlock the potential of specialty pharmacy sales teams of all shapes, sizes, geography, specialties, and areas of focus, this program was built with you in mind. Our training is available 24 hours a day, 365 days a year, and can be completed anywhere you have an internet connection either in your office or from the comfort of one of your sales reps’ homes.

Suzette D.: Graduates of CSI University will earn a Specialty Sales Certification and be able to put a sharable badge on LinkedIn and much more. Please check out csigroup.net for complete details. Again, it’s csigroup.net\university and start building the ultimate specialty pharmacy sales team today.

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About The Specialty Pharmacy Podcast

Join host Suzette DiMascio, CHE, CMCE, CPC, President and CEO of CSI Specialty Group, as she answers questions, addresses concerns and discusses the news you need to stay on top of the ever evolving world of specialty pharmacy. Tune in every episode to hear real world examples of the good, the bad and the outrageous from the experts at CSI Specialty Group, and to learn about the limitless growth opportunities available in the specialty pharmacy industry.

2018-11-02T19:14:58+00:00