On May 7, 2020, the U.S. Department of Health and Human Services (HHS), released the final 2021 Notice of Benefit and Payment Parameters (link to the actual ruling below as a pop-up window). This rule, “Encourages issuers to find innovative methods to address the market distortion.”

One of the innovative solutions PillarRx offers our clients and participating members is the IPC Copay Assistance Program. The program reduces member and plan costs associated with specialty drug spend. This member-centric program focuses on customized member communications to support the flexibility for issuers, and to educate enrollees about the issuers’ intended approach to the management of the annual limitations defined using direct support offered by drug manufacturers.

Since the HHS ruling intends to ensure issuers are fully transparent in any expected changes as to how the direct support amounts will be applied, policies must be applied in a uniform manner. PillarRx works with all non-grandfathered individual, group market coverage, and group health plans to determine whether or not to include or exclude amounts of direct support provided by drug manufacturers from the annual limitation of cost-sharing, regardless if there is a generic equivalent available.

The IPC Copay Assistance Program meets the HHS ruling, as well as state requirements. The PillarRx team understands states have the flexibility to enforce rules that require direct drug manufacturer support amounts to be counted by health insurance issuers towards the annual limitation of cost-sharing consistent with other applicable laws and rules. We are also aware some states have the same flexibility to mandate the exclusion of such amounts from the annual limitation of cost-sharing.

To maximize copay dollars available by drug manufacturers for high-cost medications, PillarRx Consulting designed this program to capture savings on behalf of the Plan and the member without jeopardizing the integrity of the existing plan design. The IPC Copay Assistance Program targets an estimated 25% of savings on total specialty spend annually.

To learn more about the IPC Copay Assistance Program and how we’ve successfully implemented the program within health plans, public entities, self-funded organizations, and business coalitions, contact us at [email protected]