HCP role in the process
Out-of-pocket example
HCP roles in each process for patients with private (commercial) insurance
Buy-and-bill (medical benefit)1
ASP, average sales price; AWP, average wholesale price; BI, benefits investigation; HCP, health care professional; PA, prior authorization; SP, specialty pharmacy.
*The drug manufacturer's service center (patient reimbursement services hub) may provide assistance with benefits investigation and help with patient co-pay costs for eligible commercial patients, subject to applicable terms and conditions.
†Timing approximate and may vary.
‡Some offices may wait for the payment from the plan to collect the out-of-pocket as opposed to collecting it up front.
§Since the drugs will be labeled with the patient's name, a separate inventory to manage patient-specific treatment may have to be created and maintained.
Specialty pharmacy (pharmacy benefit)2
ASP, average sales price; AWP, average wholesale price; BI, benefits investigation; HCP, health care professional; PA, prior authorization; SP, specialty pharmacy.
*The drug manufacturer's service center (patient reimbursement services hub) may provide assistance with benefits investigation and help with patient co-pay costs for eligible commercial patients, subject to applicable terms and conditions.
†Timing approximate and may vary.
‡Some offices may wait for the payment from the plan to collect the out-of-pocket as opposed to collecting it up front.
§Since the drugs will be labeled with the patient's name, a separate inventory to manage patient-specific treatment may have to be created and maintained.
Patient out-of-pocket (OOP) costs
-
For a majority of patients, the drug would be covered as a medical benefit
-
Co-pay and/or coinsurance vary based on the type of plan4
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In 2020, most patients had an average co-payment of $42 and average coinsurance of 19% for specialty care office visits4
-
Co-pay would vary based on the type of plan
-
The drug would likely be covered as a pharmacy benefit
-
In 2020, most patients had an average co-payment of $109 and average coinsurance of 26% for specialty drugs4
Click here to learn more about the programs some manufacturers may offer to support patients.
References: 1. Fein AJ. Accessed June 21, 2020. https://www.drugchannels.net/2016/07/how-specialty-pharmacy-is-penetrating.html 2. McCain J. Biotechnol Healthc. 2012;9(2):8-13. 3. CSI Specialty Group. Accessed June 22, 2020. https://academynet.com/sites/default/files/csi2019spreport.pdf 4. Kaiser Family Foundation. Accessed June 3, 2021. https://www.kff.org/health-costs/report/2020-employer-health-benefits-survey/
EXAMPLE
Out-of-pocket costs for patient with commercial insurance
EXAMPLE DRUG WHOLESALE ACQUISITION COST (WAC) PER TREATMENT IS $1000
Buy-and-bill
Medical
benefit
Example
based on
2021 costs*
Benefit
coverage
Specialty
pharmacy
Pharmacy
benefit
$1644
Deductible
$1644
$190
(19% of $1000)
Coinsurance
$260
(26% of $1000)
$0-$190
Total patient OOP†
$260
*Supplemental coverage or manufacturer co-pay programs may cover up to 100% of the remaining OOP costs.
†Assumes deductible has been met.
Data for benefit design based on Kaiser Family Foundation 2020 Employer Benefits Survey using data for average costs and coinsurance design for specialty drugs. This information is provided for educational purposes only and the costs presented are a hypothetical example. Coverage, reimbursement, and patient costs may vary significantly by payer, plan, patient, and setting of care.
Reference: Kaiser Family Foundation. Accessed June 3, 2021. https://www.kff.org/health-costs/report/2020-employer-health-benefits-survey/
EXAMPLE
Out-of-pocket costs for patient with commercial insurance
EXAMPLE DRUG WHOLESALE ACQUISITION COST (WAC) PER TREATMENT IS $1000
Buy-and-bill
Medical
benefit
Example
based on
2021 costs*
Benefit
coverage
Specialty
pharmacy
Pharmacy
benefit
$1644
Deductible
$1644
$190
(19% of $1000)
Coinsurance
$260
(26% of $1000)
$0-$190
Total patient OOP†
$260
*Supplemental coverage or manufacturer co-pay programs may cover up to 100% of the remaining OOP costs.
†Assumes deductible has been met.
Data for benefit design based on Kaiser Family Foundation 2020 Employer Benefits Survey using data for average costs and coinsurance design for specialty drugs. This information is provided for educational purposes only and the costs presented are a hypothetical example. Coverage, reimbursement, and patient costs may vary significantly by payer, plan, patient, and setting of care.
Reference: Kaiser Family Foundation. Accessed June 3, 2021. https://www.kff.org/health-costs/report/2020-employer-health-benefits-survey/