Directing Patients to M3P, Pfizer Notice Hints at ‘Pulling Back’ Assistance

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Directing Patients to M3P, Pfizer Notice Hints at ‘Pulling Back’ Assistance

by Lauren Flynn Kelly

Medicare Advantage insurers and their distribution partners are bracing for a busy Annual Election Period, thanks in part to multiple Part D benefit changes resulting from the Inflation Reduction Act. Adding to their concerns about likely market disruption and enrollee confusion is a new drug manufacturer letter that raises operational and financial questions about the interplay between Patient Assistance Programs (PAPs) and the Medicare Payment Prescription Plan (M3P). Patients on PAPs may pay more out of pocket In a letter dated Aug. 19, Pfizer Inc. informed Part D beneficiaries using its Pfizer Oncology Together program that they must enroll in the M3P before they can be reconsidered for the PAP. According to the company’s website, Pfizer Oncology Together provides financial assistance with out-of-pocket (OOP) deductible, co-pay, or coinsurance costs for eligible patients who have been prescribed certain Pfizer Oncology oral and injectable medicines. While drug coupons/discount card programs are explicitly prohibited from use in the Part D program, PAPs can interface with health plans and support qualifying enrollees by operating outside the Part D benefit so that the assistance does not count toward a patient’s true-out-of-pocket (TrOOP) cost. That’s important since the TrOOP will determine whether individuals hit their catastrophic coverage threshold for Part D, which will be $2,000 in 2025 and serve as the limit for Part D beneficiaries’ OOP costs. In the catastrophic phase, Part D plans and manufacturers will pick up a greater share of costs while Medicare will pay a smaller share. For Part D beneficiaries who currently rely on PAPs, changes like the one being effectuated by Pfizer could require them to pay more out of pocket than they currently do. “The $2,000 OOP cap is more than some may currently pay and the M3P program does not lessen the amount owed, but it does spread out the costs over the course of the remaining months in the year,” says Jennifer Snow, founder of health policy and consulting firm Apteka LLC. When asked how it planned to determine whether patients can afford the PAP medications, Pfizer clarifies that the new requirements for Part D patients who request assistance with a Pfizer product include attesting to "inability to afford their co-payment" and "[n]ot yet reaching their annual out-of-pocket maximum (after which they would have a $0 co-payment for covered, branded medicines)." Plans are not thrilled about ‘additional work’ of M3P The PAP notice raises “a concern because it’s saying we may or may not help you, but go and enroll and figure out what your monthly costs are going to be, and then come back to us,” continues Snow. And, she adds, “plans are likely not that eager to have people enrolled in the program because then they have to worry about invoicing them and all the rest. In general, if a patient is on a brand medication, it may work out for them, but for plans, it’s additional work.” As for why Pfizer is implementing the new requirements, the program is "designed to serve patients with the greatest financial need," explains a Pfizer spokesperson to AIS Health. "As more options become available to help patients afford their medicines, including the Medicare Prescription Payment Plan, Pfizer reviews and updates the eligibility criteria of its PAP to ensure we can continue to provide a wide range of medicine free of cost to eligible patients."