One of the most attractive reasons for easy access to biosimilars was their inherent promise that lower costs would reduce patient out-of-pocket expenses. We’re not alluding to the potential for lower total health spending resulting in reduced plan premiums. That may actually happen over the long term, if biosimilars ever become pervasive. Specifically, we thought biosimilars uptake would allow invaluable medicines to be more affordable to the patients themselves.

Consider the following scenario, which likely has occurred in a few physician offices around the country. Ms. Pamela Townshend is told by Dr. Robert Daltrey, “Pamela, I’m going to write you a prescription for Remicade^® for your moderate-to-severe Crohn’s disease symptoms.” (Sorry, I never get tired of hearing this naturally occurring phrase in broadcast commercials.) “We first have to file the prior authorization paperwork for your medication with your plan before you can come in for your first infusion.” Ms. Townshend goes home, goes online, and finds that Remicade is on her plan’s specialty tier—subject to 20% co-insurance. Her plan has a maximum payment of $225 in place, but she will reach that, assuming the drug is covered by the medical benefit (not the pharmacy benefit, which has a $500 deductible). Knowing that she will be taking the drug for some time, she’s alarmed at the annual out-of-pocket cost. Frantic, she phones Dr. Daltrey’s office, pleading for a lower-cost alternative.

Of course, we think, “Biosimilars to the rescue!” And of course, that’s not quite right. Instead, it’s “copay coupon to the rescue.” Even if her plan was one of the minority that preferred biosimilar Inflectra^® or Renflexis^®, and thus required a lower out-of-pocket payment, Ms. Townshend would still be offered a coupon from Janssen that would reduce her personal costs to as little as $5 per infusion. In fact, she may have been informed of this before exiting the doors of the Moon Medical Group, allaying any panic about the affordability of her medicine. Often, the medical group’s billing office can start the copay coupon application process at the time of the office visit.

Realistically, very few in the general population will worry that Remicade costs the health plan over $3,000 per infusion (for a 60-kg person) when they have to pay over $200 out of pocket. One can make the argument that the patient is even less concerned about the real cost of the medication when their cost share is only $5. Here’s the main point: Every reference biologic manufacturer facing biosimilar competition (except the makers of reference epoetin) has a copay coupon program (Table). The biosimilar manufacturers also provide copay coupons (e.g., Pfizer enCompass or Coherus Complete). In other words, the cost-sharing differential in preferring biologics may play a limited role in patients migrating towards biosimilar use.

Reference Brand	Patient Assistance Program	Copay Costs to Patient After Coupon
Remicade	Janssen CarePath	$5 per infusion
Humira	Humira Complete	$5 per month
Neupogen	Amgen Assist 360	$0 to $5 per dose or cycle
Neulasta	Amgen Assist 360	$0 to $5 per dose or cycle
Herceptin	Genentech BioOncology Co-pay Asssistance Program®	$5 per dose
Avastin	Genentech BioOncology Co-pay Asssistance Program	$5 per dose

To the extent that patients do not have to pay the full, intended cost share and then receive a rebate later from the patient assistance program, they would not be subject to sticker shock.

We sought data on whether virtually all biologic manufacturers provided copay coupon programs; it seems this specific data point does not exist or at least not been published. Holly Campbell at PhRMA pointed me to a study using 2013 data by Pat Gleason and colleagues at Prime Therapeutics, showing that drug coupons were used in 44% of 264,801 specialty prescriptions in their analysis. In the anti-inflammatory area, that percentage was 61%. (Note that this was before the approval of any biosimilar competition.) They also found that these coupons reduce did directly lead to less prescription abandonment.

Michael Kleinrock, Research Director at the IQVIA Institute for Human Data Science, shared with us the latest information they had compiled. He noted that overall, “18% of brand scripts use a coupon” and “there are high profile cases like the autoimmune category where lots of the drugs are couponing to $5.”

Copayment use in certain biologic markets can be extremely high. According to Luke Greenwalt, VP, Market Access of IQVIA’s Admundsen division, “If you look at autoimmune, we see 80-90% copay penetration rates for commercial markets—meaning that nearly all patients who can use a card do so.” He explained, “That is driven by competitive pressures, wide proliferation of cards, direct-to-consumer [messaging] that references patient-savings programs, high utilization of hubs/specialty pharmacies who know how to get access to programs, and high copays. In general we also see that the more a patient is asked to pay, the more likely they are to use a copay card—regardless of class.”

In doing a random survey of biologic manufacturers, we couldn’t identify any that didn’t employ a copay coupon program. Highly experienced pharmacy executives like James Kenney, Jr., MS, RPh, President of the Academy of Managed Care Pharmacy, confirmed that they also couldn’t recall any biologic drug makers that don’t offer copay coupon programs today.

Simply because the copay assistance programs are ubiquitous does not mean they are used every time a prescription is written. There is good reason to expect that they will be used more often in the future, not less. It does mean patient cost-sharing differentials for those covered by private, commercial insurance is not yet a real factor in choosing biosimilars. Health plans and insurers that want to increase biosimilar uptake can simply exclude coverage of the reference product. This has not been the case, of course, with infliximab. Payers can use copay accumulators that prevent the copay card savings from being applied to any deductible the patient may owe. Patients don’t really understand how these work, and to be honest, I doubt I could pass a test on them.

The use of a simple, unique biosimilar tier, with relatively low copayments, might help spur patients to ask for the biosimilar. These special tiers have not been implemented, largely because so few biosimilars are available for prescription today.

The Association of Accessible Medicines, in their Failure to Launch White Paper (part 2), stated “patients do not seek out biosimilars from their providers because the difference in their cost-sharing is rarely communicated to the patient or the provider.” I’ll go one step further: Because of copay coupons, the final cost difference to the patient may be far less than one thinks.