Pitney Bowes pioneered the concept in 2002 when the company reduced copayments for diabetes and asthma drugs effective for managing these prevalent and costly conditions. The initiative resulted in increases in medication adherence and lower overall health care costs per plan participant.

Marriott International, Inc., Proctor & Gamble Co., and Eastman Chemical are among other employers who have reduced or eliminated copays for maintenance medications.

The University of Michigan (UM) launched a two-year pilot program in 2006 for pharmacy plan members who have diabetes. The program had those members pay no or low copays for drugs that control blood sugar, lower blood pressure, reduce risk of heart and kidney problems, and ease depression. UM will evaluate the program’s success in encouraging the use of medicines that mitigate the long-term effects of diabetes.

In many cases, reduced copayments are linked to participation in programs that help employees learn to better manage chronic conditions. The highly successful Asheville Project is an example. The 10-year-old pharmacist-coordinated diabetes management program waives participants’ copayments for diabetes medications and supplies.

The American Pharmacists Association (APhA) Foundation developed a similar program, HealthMapRx, adopted by 80 U.S. employers. Employers using HealthMapRx reduce or waive copayments as a financial incentive for employee program participation. This increases adherence, improves health outcomes, and decreases medical costs.

Combining Incentives
The Cleveland Clinic Employee Health Plan is piloting a program that combines reduced out-of-pocket costs for statin medications for high cholesterol with pill splitting. The innovative program has increased statin adherence while minimizing the net cost increase to the Cleveland Clinic’s pharmacy benefit plan.

The Cleveland Clinic launched the cholesterol program in 2006. The program features a flat copay of $6 for a 90-day supply of generic statins and $8 for a 90-day supply of Lipitor® or Crestor® when purchased from one of the Cleveland Clinic’s nine pharmacies. It was a significant change from the Cleveland Clinic’s coinsurance structure. There, the average member payment for a 90-day supply of brand-name statins was $75 to $90.

To qualify for the low copay, members were required to participate in a half-tablet program and purchase statin prescriptions from a Cleveland Clinic pharmacy. Members needing the highest dose of their statin medication to control cholesterol levels were exempt from the half-tablet requirement. Educational materials on cholesterol management and a program invitation were sent to active members filling a statin prescription through a Cleveland Clinic pharmacy benefit plan from 2003 onward.

About 38 percent of the plan’s eligible members have participated in the program. In year one, the Cleveland Clinic documented a 20 percent increase in complete adherence in its population of statin users. Members who picked up all their statin prescriptions for the year were counted as completely adherent.

The Cleveland Clinic tracked the behavior of new statin users, in particular, because this group is typically at high risk for a drop in compliance during the first year. More than 50 percent of new statin users who participated in the cholesterol program picked up all their prescriptions in the first year. This compares to only 18 percent of those who did not participate.

The Cleveland Clinic is conducting more analysis. They intend to track adherence over a longer time, compare rates between participating and non-participating members, and evaluate the impact on cholesterol levels.

Implications of Changes
More data is needed on the net effect – both short- and long-term – of decreasing member cost share. It is critical to monitor documented clinical and economic outcomes of programs that employ low or reduced copayments to encourage adherence.

There is evidence that increased cost sharing is associated with lower rates of drug treatment, less adherence and more frequent discontinuation and/or interruption of therapy. Whenever member cost share is increased or decreased, employers should monitor changes in prescription drug utilization and costs for medical services.