Payers will have to carefully mull limited options.
Patients see drug couponing as a way to lower or avoid cost sharing on brand-name prescription drugs. Payers view drug couponing as undercutting their pharmacy benefit design. Pharmaceutical companies see drug couponing as the key to greater sales, especially when they are in nonpreferred formulary positions (i.e., after generic competition is launched).
In a value-based pharmacy benefit design, the payer assigns medications that are highly effective, lower cost, or both to lower formulary tiers, to make them attractive to plan members. On the other hand, agents that are deemed to be of less value are placed in higher tiers, or even excluded from coverage. Simply, lower cost sharing means greater incentive to use and better sales for the industry. However, drug couponing, which is now ubiquitous, remove the patient incentive to use higher value drugs (and the disincentive to use lower value agents).
In the case of biosimilars versus originator medications, drug coupons offered by the manufacturer of Enbrel®, for example, actually make it less expensive for the patient to purchase the originator than the biosimilar, assuming a lower-copay biosimilar tier. That is, unless Sandoz, the maker of the approved etanercept biosimilar, matches Amgen’s couponing program. In that case, there would be incentive or disincentive for either product, from the patient’s perspective.
In dealing with couponing programs, payers have 3 options: (1) let things be and hope that if patients have little cost sharing perhaps adherence will improve overall, (2) ban the use of couponing by members (in other words, don’t allow network pharmacies to accept them), or (3) exclude from coverage any drug for which coupons are offered (this would be a lot of drugs today).
According to a new article in the New England Journal of Medicine, couponing has boosted prescriptions for branded medications by greater than 60%. For the nation as a whole, every copayment coupon adds up to $120 million over the first 5 years after a generic drug is introduced. For the manufacturers of 85 medications that first faced generic competition between 2007 and 2010, couponing boosted spending anywhere from $700 million to $2.7 billion over a scenario in which couponing did not exist.
To preserve the value of biosimilars, payers will have to carefully mull their limited options. Excluding coverage of originator products that have copayment coupons may not be practical, because of the delicate situation regarding switching of biosimilars and lack of an interchangeable designation, especially for patients on established therapy. Banning the use of copayment coupons seems like a more reasonable option for payers, but one that may cost them members, particularly in today’s heated competitive market.