As pharmacy benefit managers (PBMs) face more scrutiny about their practices and rising drug costs, Express Scripts unveiled new solutions last week that aim to improve price transparency and drive down costs.
St. Louis-based Express Scripts is the PBM business of Evernorth, a subsidiary of Cigna. One of its new solutions is called the Copay Assurance Plan, which will cap consumers’ out-of-pocket costs for drugs through their prescription drug benefit. Out-of-pocket costs will be limited to $5 for generics and specialty generics, $25 for preferred brand drugs and $45 for preferred specialty brand drugs.
“The reason we’re doing that is the data shows that once you get to $50 or more, the number of patients that abandon a prescription is four times as much as if their copays are as low as $10,” said Adam Kautzner, president of Express Scripts, in an interview. “That’s really important for us as drug prices continue to increase and patients do have some challenges there.”
Express Scripts isn’t just targeting consumers with its new advancements, but its employer, health plan and government employer clients as well. In addition to the Copay Assurance Plan, the PBM also announced its new ClearCareRx offering, which will provide clients with more transparent costs.
Clients who choose the ClearCareRx offering will pay Express Scripts the same price the PBM pays pharmacies for a prescription, and will receive 100% of the drug rebates Express Scripts receives. Clients also just pay a flat per-member-per-month fee that covers administrative services, PBM product services, reporting and analytics. In addition, Express Scripts will be required to meet certain financial and clinical measurements, Kautzner said. If the company doesn’t meet these measurements, clients will pay less.
“We have to hold ourselves accountable,” he said.
Express Scripts is also improving its disclosure practices, including providing digital pharmacy benefits statements with prescriptions starting in 2024. These statements will provide information on drug prices and out-of-pocket costs. In addition, Express Scripts will launch a microsite with disclosures and filings with the SEC, and will offer a financial and fee disclosure to clients who opt for spread pricing (a PBM practice in which the PBM charges the plan sponsor more than they paid the pharmacy for medications and then keeps the difference).
The company’s announcement comes at a time when PBMs are increasingly facing regulatory pressure. This includes the Pharmacy Benefit Manager Transparency Act of 2023, which was introduced in the Senate in January and aims to ban spread pricing and clawing back reimbursements. Last month, the House introduced the Drug Price Transparency in Medicaid Act, which would also ban spread pricing in Medicaid programs.
When it comes to rising drug costs, the actions by Express Scripts show progress, said Randy Rutta, CEO of the National Health Council.
“Patients, particularly those with chronic conditions, need to be able to anticipate their health care costs,” Rutta said in an email. “From what we’ve seen so far, this new program is a step in the right direction. By increasing the predictability of out-of-pocket spending on medications, people with chronic conditions can better budget and plan for such costs. Lower copays will also help increase patient adherence to prescribed medicines, which is critical for people in managing their chronic conditions. We look forward to learning more about the program and the potentially positive impact it could have on the industry as a whole.”
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