Webinars & Videos

Are You In a Copay-Card Conundrum?

January 4, 2023

Capital Rx

Do you have a copay card program in place? If so, your PBM may be reaping tremendous hidden profits off of it. So go ahead, ask your PBM to disclose all of their fees for this program… but be ready for some sticker shock.


Hopefully, you've had a chance to watch our two prior videos with simple questions that you should ask your PBM about prior authorization and auto-refill. For this third and final episode in the series, we're turning our attention to copay card program fees. Now, copay card programs take advantage of manufacturer co-pay assistance funding to help plan sponsors reduce their program. These programs can generate savings, but most plan sponsors don't realize how immensely profitable the programs can be for the PBMs who run them. You see the vast majority of PBMs charge a shared savings arrangement often retaining as much as 25 or 30% of the copay card value as a fee. And the PBMs portion of the shared savings can add up very quickly.

In this example, which is for a common drug used to treat psoriasis, the manufacturer offers up to $20,000 in copay card value annually. Under a 25% shared savings arrangement, that's $5,000 in retained fees for the PBM for a single patient. And while there are operational costs for managing a program like this, they are nowhere near that $5,000 level. Any efficient PBM really should be able to run this type of program under a low flat administrative charge. Now, this sky-high profit margin creates a potential conflict of interest. Put simply if the PBM stands to gain $5,000 from this copay card arrangement, they have a powerful financial incentive to make sure that the patient gets this particular medication, even if a lower-cost alternative exists.

So if you have a copay card program in place, here's a question that you should ask your PBM today. What was the total of all shared savings fees for my copay card program over the past year? Now, if you think those fees look high, ask your PBM to convert you to a reasonable, flat administrative charge. And if you're curious to know what an appropriate range is for that charge, contact Capital Rx. That's how we do business.

That concludes our video series of three questions that you should ask your PBM. Stay tuned for more helpful videos coming your way in the near future.

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