It’s become a well-accepted mantra among physicians to “prescribe generics whenever possible” as a means to keep out-of-pocket costs down for patients. But when a brand-name medication is the only or best option to treat a condition, manufacturer coupons and discount cards can sometimes help patients save money at the pharmacy.
Physicians generally do not receive much information about how such direct-to-consumer (DTC) advertised savings programs work, and should be mindful of their numerous caveats and limitations.
The first challenge is keeping up with the rapid growth of such programs. “Newer, more expensive drugs will almost always have some sort of patient assistance program,” says Ana María López, MD, MPH, FACP, president-elect of the American College of Physicians. “I think a lot of people are probably aware that these are out there. But there are so many plans and it’s very variable; it’s hard for a physician or office to keep track of it all.”
Several years ago, coupons and discount cards began replacing the drug samples pharma reps used to offer physician offices—and quickly. The Physician Payments Sunshine Act of 2010 increased scrutiny of financial relationships between clinicians and pharmaceutical manufacturers. According to health data firm IMS Health, coupons were available for just 86 indications in 2009, and shot up to 395 indications by 2012.
Today, discount repository internetdrugcoupons.com (see sidebar) claims to offer discounts on more than 50,000 medications nationwide.
Rules and restrictions
Federal anti-kickback statute prohibits these discounts, which are funded by manufacturer subsidies, from being used with drug coverage provided through Medicaid or Medicare Part D.
However, patients with government insurance may use the coupons for drugs that are not covered by their formularies, notes Edward Kaplan, a senior vice president for Segal Consulting, which provides benefits, compensation, and human resources advice to employers. “It’s rare—and applies mostly to specialty drugs,” he says.
Most often, patients acquire drug coupons by downloading them after hearing about them through DTC advertising, says Lopez. For example, a TV commercial for Nexium (esomeprazone), used to treat heartburn, concludes with a message that if consumers have trouble paying for the medication, AstraZeneca “may be able to help.”
Clarify benefits, understand hurdles
There are also circumstances in which a patient will request a prescription to match a coupon they’ve obtained, says George G. Ellis, Jr. MD, FACP, chief medical adviser for Medical Economics.
“We run into this difficulty constantly because pharma is advertising directly to consumers,” he says. Ellis declines to write a prescription under these circumstances.
Similarly, time limitations on discounts generally are not mentioned in TV advertising. “You have to be careful because these copay assistance programs are not guaranteed forever,” says Kaplan. “The manufacturer can discontinue them at any time.”
Patients can then find themselves having to pay the full copay out of pocket. And even if a cheaper alternative exists, patients may be reluctant to stop taking a brand to which they’ve become loyal, Kaplan explains.
Therefore, physician offices should warn patients that there’s no guarantee a pharmacy will accept a given coupon or that the savings will continue long-term. “We used to have some coupons [in the office] for specific drugs, but even those applied to a very narrow group of people,” Lopez says. “You have to be careful you know who is receiving them so that they won’t end up disappointed.”
If a patient requests a medication that is appropriate and recommended for his or her condition, Ellis may be willing to give it a try, he says, but insurer red tape may still complicate matters.
“Take a drug like Farxiga (dapagliflozin) [used to treat Type 2 diabetes]. They want to see you first tried metformin and possibly something else before you step it up to Farxiga,” he says. “We’re being forced through step therapy, and between pharma and the insurance industry, we are squeezed really badly.”
Working with reps and vendors
Key resources for understanding the ins and outs of manufacturer discounts are the pharmaceutical representatives themselves, although physician interaction with reps has diminished in recent years. Drug manufacturer websites often spell out additional guidance for prescribers.
“I don’t do lunches anymore or go to dinner meetings,” says Ellis. “If a rep comes in and asks to talk to me for a few minutes, I’ll give them two minutes. I won’t see more than four or five reps per day, and all I care about hearing is what’s new and what they can offer to help my patients.”
During these brief encounters, reps often explain and provide coupons to distribute to patients. Ellis will then ask the rep to give the coupons to staff at the front desk, who will hold them and document that inventory. “We have a logbook so the staff know that if a branded drug is being prescribed, they know what coupons are up front that patients could use.”
For practices that have the capability, one or two employees could become the experts to talk with patients about prescription-savings opportunities, says Lopez. “Or it might be as simple as suggesting to a patient to go online and see whether the manufacturer offers a savings plan.”