Want to increase member participation in a specialty medicine solution? Reducing or waiving cost share is a good start.

One employee at a self-funded employer received Gammagard infusions twice a month for a rare autoimmune disease. Every other week, she and her husband drove two hours round-trip to an infusion center, and he took two half-days off work on back-to-back days to go with her. Between the drive, the waiting room, and the insurance approvals, infusion day was a regular strain on the whole family.

Within a few weeks of her employer launching Leap, she was receiving the same Gammagard infusion at home, on a schedule built around her life. 

For many employees like this one, the decision to switch to Leap is one to think through. But what else encouraged this employee to choose Leap? No copay. 

Her employer had waived it as part of a broader activation strategy. Six months in, the employer was on track for nearly $1 million in annualized savings per 10,000 covered lives. Please note: Savings may vary by employer, plan design, and member population. 

The waived copay didn’t produce that result on its own, but it removed one more reason for a member like her to stay with what she knew. For self-funded employers, cost share is something the employer controls directly, and it’s an effective tool benefits leaders and consultants have for turning a promising savings analysis into savings the plan actually captures.

Potential savings can only materialize when a member chooses Leap, and reducing or waiving that member’s cost share is one way employers can encourage more more members to make that choice. Here’s how it works, how it fits into a plan design, and how to implement it.

What is cost share?

Cost share is the portion of a covered service the member pays out of pocket. It usually comes in four forms:

• A copay is a flat dollar fee per service.
• The deductible is what the member pays before the plan starts covering services.
• Coinsurance is a percentage of the allowed amount the member pays after meeting the deductible.
• The out-of-pocket maximum is the annual ceiling on what a member can pay before the plan covers 100% of covered in-network costs.

Specialty infusion affects this in a way that primary care doesn’t because of the high cost of specialty drugs. 

For example, a single hospital-billed Ocrevus 600mg encounter can run about $89K. That’s well above the annual deductible in most employer plans. Members on long-course therapy often meet their deductible with their first infusion of the year and move quickly toward their out-of-pocket maximum after that. 

What does waiving or reducing cost share look like within a plan?

Most employers already use cost share to shape member behavior, such as: 

• Lower copays for generic drugs.
• Higher coinsurance for out-of-network care.
• Tiered networks that reward members for choosing preferred providers. 

Waiving or reducing cost share for specialty infusion applies that familiar approach to one high-cost category.

In practice, the employer sets a lower cost-share level, such as no copays, for infusion care delivered through a preferred solution that can reduce costs for the employer, improve the patient experience, or both. Providers in a preferred solution are identified by their National Provider Identifier (NPI) so the plan can identify those encounters on the claim and apply the lower cost share to them, without changing the broader network, the medical policy, the pharmacy benefit manager relationship, or the member’s ID card.

Employers typically choose from a range of designs, depending on how strong an incentive they want:

• Waive the deductible and coinsurance entirely, so eligible infusion encounters cost the member $0.
• Waive coinsurance but keep the deductible in place.
• Replace coinsurance with a flat, low copay.
• Lower the coinsurance percentage for eligible encounters.

Once the employer health plan adopts the change, the carrier or TPA (third-party administrator) configures the change within its existing claims process, and the health plan keeps full control of prior authorization, utilization management, and medical necessity decisions. For members, coverage works the way it always has, except that they owe less when they choose the preferred option. 

How much can waiving or reducing cost share impact utilization?

Because of the high cost of specialty drugs and the potential for hidden cost markups that exist, there's a real incentive for employers to drive utilization in programs that acquire these drugs at the cheapest cost and eliminate the markups passed to employers. 

In Leap’s experience, the more employers do to reduce or eliminate cost share, the higher their utilization rates will be. Internal data shows that among Leap clients, member participation was up to sevenfold higher when waiving deductible versus waiving only copay. 

Picture this from the member’s side. A member who has received infusions at the same hospital outpatient clinic for two years has a routine, a nurse they know, and a parking spot they like. Even if that routine costs them a full workday every cycle, staying put feels easier than trying something new. Plus, some members have just accepted that “infusion day” is going to be a chore. 

A reduced or waived cost share gives that member a concrete reason to consider another solution that they might prefer. 

Cost share impacts for PPO vs. HDHP members

Plan type changes what a cost-share program can look like. Employers with both Preferred Provider Organization (PPO) and high-deductible health plan (HDHP) options usually need two designs.

PPO members

PPOs generally give employers the most flexibility. The plan can waive the deductible and coinsurance for infusion or injection appointments outright, so a member on Entyvio every eight weeks or Ocrevus every six months pays nothing for eligible infusions coordinated through the preferred solution. The design is simple to explain to members and produces the strongest incentive on the continuum described above.

HDHP members

HDHPs that permit health savings accounts (HSAs) are subject to IRS rules that limit what a plan is initially able to cover. To preserve members’ HSA eligibility, these plans generally can’t cover non-preventive services until the member meets the plan’s minimum deductible. The IRS list of preventive care for chronic conditions is narrow and doesn’t typically extend to specialty infusion therapy, so waiving the deductible for infusion encounters could put HSA eligibility at risk for every member enrolled in that plan.

The cost of infusion therapy works in the employer’s favor here. Because of the high cost, a design that waives or reduces coinsurance after the deductible captures nearly every type of infusion or injection appointment after the first one. 

Employers may be able to pair that post-deductible design with an employer HSA contribution or another incentive that offsets the member’s deductible exposure without affecting HDHP status. Because these rules carry real compliance consequences, employers should confirm any HDHP design with benefits counsel or a tax adviser before it goes live.

How to successfully implement a cost-share program

Size the opportunity with your own claims data

Start with a claims-based impact analysis (you can request one from Leap here) built from the employer’s own data. The analysis estimates the savings opportunity drug by drug and member by member, which gives the employer an accurate picture of what the waiver may cost and what it can return before anything changes.

Choose a design for each plan type

Use the analysis and input from benefits counsel to decide how strong the incentive should be. Employers could consider plan types that pair a full waiver for PPO members with a post-deductible design for HDHP members (if the employer offers both a PPO and an HDHP).

Configure the benefit with the carrier or TPA

The configuration with the carrier or third-party administrator (TPA) is crucial. Leap works alongside the carrier or TPA through setup.

Update plan documents and member notices

A cost-share change typically requires a plan amendment and updates to the summary plan description (SPD) and the summary of benefits and coverage (SBC). Changes made mid-plan-year may also trigger advance notice requirements, so employers should confirm timing and notice obligations with benefits counsel.

Tell members about the change

Members can’t respond to an incentive they don’t know about. HR teams can announce the change through their usual benefits channels. With Leap, Care Guides can reach eligible members directly with employer authorization through email, phone, and SMS.

Measure member participation

Track how many eligible members choose the preferred specialty medicine solution after the change. 

See what a cost-share program could save your plan. Request a claims-based savings analysis.