Helping all patients access needed therapies, not just those with assistance programs.

The high prices charged for prescription drugs is a well-understood challenge that touches millions of Americans. Increasingly, however, a subset of drugs referred to as specialty medications has dramatically heightened the situation – creating an unsustainable affordability crisis and preventing access to needed therapies. These specialty medications are often complex treatments that require administration in a clinical setting. For Express Scripts’ commercial clients, specialty drugs are used by fewer than 2% of patients but account for more than half of all spending on prescription drugs. This is because many of these drugs come with a price tag in the hundreds of thousands and some cost more than one million dollars.

While these therapies represent meaningful advances in science, their costs are often unjustifiable. One way that manufacturers try to soften the blow for patients is through copay assistance programs. Deemed as charitable, in practice the programs often serve primarily to drive patients toward these high-cost treatments over other, more affordable options. Rather than simply setting lower prices, these programs temporarily shield a few patients from out-of-pocket costs, but allow drug manufacturers to charge health plans and their patients enormous prices. Those prices are borne by everyone in the form of higher premiums, higher out-of-pocket costs, and other pressures on plan design.  

Copay assistance programs also serve to undermine the tools that health plans and pharmacy benefit specialists use to help keep costs down, like encouraging the use of clinically equivalent, but lower cost medications. That’s why health plans must be able to leverage these programs to lower costs for all plan members. Evernorth, for example, has programs that ensure access to affordable prescriptions for all patients, such as the SaveOnSP program, which maximizes the drug manufacturer assistance dollars available, sets the participating patient’s copay at $0, and minimizes the impact to plan costs. We believe solutions must be designed to allow all patients to have access to affordable prescriptions and benefit from lower costs, rather than just those using a medication that has an assistance program.  

• Policymakers should prioritize solutions that are designed to allow all patients, health plans, and businesses to benefit from the copay assistance programs that drug manufacturers fund, rather than solely patients that manufacturers target with coupon programs.