Fast Facts: Increasing Patient Cost-Sharing and Using Tiered Formularies

Expenditures on pharmaceutical products have been rising 10% every year for the last several years, leading to double-digit increases in prescription drug spending. Healthcare payers continue to create drug formularies to cap spending and reduce costs.

Formularies are lists of drugs covered by a health plan or pharmacy benefit manager (PBM). Payers can create formularies with several tiers, each with a different level of patient cost-sharing – the amount that a patient pays out of pocket for a drug. Drugs that are typically placed on specialty tiers include treatments for cardiomyopathy, cancer, rheumatoid arthritis, multiple sclerosis, hepatitis C, and other conditions.

We have introduced the Fast Facts: Increasing Patient Cost-Sharing and Using Tiered Formularies microlearning module to help equip sales and account management teams with the most relevant and current information on how patient cost-sharing and tiered formularies affect various stakeholders in our value-based healthcare system.

Fast Facts: Increasing Patient Cost-Sharing and Using Tiered Formularies gives an overview of various tiered formularies that affect patient cost-sharing, types of cost-sharing, and how the prevalent practices of the cost-sharing tactics affect different stakeholders. Most importantly, sales and account management professionals will learn to address access challenges that commonly arise for patients and customers.

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How Tiered Formularies Affect Patient Cost-Sharing

 Health plans and PBM formularies typically include between three and five different tiers, with each tier placement depending on the products’ cost and clinical efficacy as evaluated by the payer.

Each tier has a different level of patient cost-sharing. The higher the tier, the greater the out-of-pocket costs to the patient. Patients have no say in opting for a lower-cost drug on a lower tier.

For specialty drugs, cost-sharing is in the form of coinsurance, which means patients pay a set percentage of the cost of a drug. Copays are another form of patient cost-sharing, with set amounts per prescription.

Additionally, some plans, especially those sold on the health insurance marketplace, may require patients to pay a deductible for prescription drugs.

Patient cost-sharing and tiered formularies affect all stakeholders in the healthcare value chain. Effective steps, if taken early, can offset the consequences.

Make Fast Facts: Increasing Patient Cost-Sharing and Using Tiered Formularies course a part of your pharmaceutical sales training program. Click here to chat with our training expert.