• 12 Nov 2012

    Health Plans and PBMs Take Action to Limit Utilization of Co-Pay Offset Programs

    Chris Wheeler, Director, Co-Pay Strategies, Zitter Health Insights

    A disturbing trend is emerging in the co-pay assistance marketplace as marketers managing co-pay offset programs face increasing resistance from payers and pharmacy benefits managers (PBMs).  Payers and PBMs complain that co-pay offset programs raise costs by encouraging the use of branded drugs over generics.  They argue that co-pay programs undermine their ability to manage drug utilization through formulary design. Our Co-Pay Offset Monitor (COM) tracks these trends and provides strategic insight into actions and reactions of all relevant stakeholders.

    In this year alone, COM has identified three major payer/PBM actions against co-pay offset programs.  CVS Caremark, United Healthcare, and Blue Cross Blue Shield of Rhode Island have all introduced measures limiting utilization of co-pay programs.  These measures are summarized in Figure 1.

    Figure 1. Health Plan and PBM Policies Impacting Patient Access to Co-pay Offset Programs.
    Health Plan and PBM policies
    The effect of payer/PBM co-pay program utilization measures can influence drug utilization, limit patient options, and impact important clinical outcomes.  Outright bans are the most drastic payer/PBM against co-pay programs, but not the only action.

    According to an October 2012 survey of 202 endocrinologists and primary care physicians treating Diabetes (one of the most active categories in terms of co-pay program utilization) patients, 22% of physicians indicated that they have encountered payer access controls limiting the utilization of co-pay offset programs, or counteracting program benefits. (See Figure 2).  The most common payer control cited by physicians is payer switching the drug to non-preferred formulary status.

    Figure 2. Physician Perceptions of Payer Controls on Patient Access to Co-pay Offset Programs.

    Physician perceptions

    Payers/PBMs employ several other tactical approaches to combat co-pay programs including public relations campaigns, as summarized in Figure 3.

    Figure 3. Possible Payer Actions Reducing Patient Access to Co-pay Offset Programs.
    Possible Payer Actions

    These findings have worrying implications for brands sponsoring co-pay offset programs. Not only is it possible that payer policies are impacting patients’ ability to take advantage of co-pay offset programs, but the perception by some physicians that health plan policies prevent co-pay offset program use could also decrease utilization by discouraging physicians from supplying or recommending co-pay cards to patients.

    Fortunately, marketers are not without recourse.  Payers/PBMs moving to limit patient co-pay offset program usage face significant obstacles. One obstacle is backlash from physicians, patients, and employers who perceive co-pay offset programs saving patient money and increasing access to clinically useful therapies.  As part of its overall framework for driving informed co-pay decision making, COM provides useful insights to address payer co-pay program strategies.  COM provides research data on stakeholders’ perceptions of the positive impact of specialty co-pay offset programs on clinical outcomes.  These insights help raise public awareness of the negative implications of co-pay program limitation efforts.  COM also provides deep insight into the landscape of co-pay program types and benefit designs to provide marketers with sound alternatives to traditional co-pay programs.


    [1] Jon, Camp. ” CVS Disfavors Some Drugs: Company’s Pharmacy-Benefit Business Steers Customers to Cheaper Therapies .” Wall Street Journal (Online) 19 Nov 2011<
    [1]“UnitedHealthcare to Limit Acceptance of Manufacturer Copay Coupons.” 29 Aug 2012
    [1] “Cat Fight on Co-Pay Offsets.” 14 Mar 2012 <>
    [1] United Healthcare. “Do drug copay coupons undermine your benefits strategy.”; Cahn, L. “How to Combat Pharma’s Costly Coupon Programs.” Managed Care. May 2012. <>