Reimagining the Pharmacy Benefit
Express Scripts Innovates to Promote Greater Patient and Client Affordability, Transparency, and a Simpler System
New Solutions Move Industry Forward
Pharmacy Benefit Managers – or PBMs – play a vital role in the health system, negotiating lower drug prices and ensuring patients have safe access to needed medications. Employers, health insurers, and public sector entities everywhere rely on pharmacy benefit services to control costs and help keep workforces healthy and productive. They partner with PBMs because of the significant value created by PBMs; without them, pharmacy costs would be notably higher.
None of this means the system cannot be improved. Policymakers and other stakeholders have asked important questions around issues of transparency, pricing structures, and affordability. Patients and employers should be confident that their pharmacy benefits are delivering value and meeting the promise of the system.
That’s why Express Scripts, Evernorth’s pharmacy benefit management company, has announced a series of new solutions to further advance how it delivers services for those we serve. Demonstrating what’s possible, these programs will improve affordability, predictability, and transparency. Available starting in summer 2023, these innovations provide a roadmap for how the system can operate. It is private sector action that reimagines the pharmacy benefit and directly addresses the issues most pressing for patients, employers, and policymakers.
A Fully Transparent PBM Model
Many of the questions policymakers have for pharmacy benefit companies revolve around the structure of plans, their negotiating tools, and how PBMs are compensated for the services they provide. These are the behind-the-scenes ways PBMs and their clients work hand-in-hand to operate the benefit. Tools like rebates, spread pricing, and value-based purchasing are all important ways that PBMs generate savings for their clients, and many employers choose these arrangements over other administrative fee-based alternatives. Still, we know questions remain about how savings are being passed onto patients and others.
A misperception that PBMs are not transparent has allowed the industry to be characterized incorrectly, eroding trust in the system. The patients, employers, health plans, and government clients that rely on pharmacy benefits deserve to know what they’re paying and how that compares to what pharmaceutical companies and pharmacies are charging for a medication. That’s why Express Scripts has announced two new actions: one for patients and another for its employer clients.
For patients, every prescription will soon include an easy-to-understand pharmacy savings statement, which will provide details on the price of the drug, what it costs the consumer at the pharmacy counter, and the value generated by the PBM. This benefit will be implemented across all 65,000 pharmacies in Express Scripts’ networks.
To erase any doubt and simplify the system for employers and other clients, Express Scripts has created the ClearCareRx program. The idea is simple: the client pays what Express Scripts pays pharmacies for the client’s prescriptions and the client gets 100% of all drug manufacturer value – inclusive of any and all discounts and rebates tied to utilization. In return, we will charge one simple per member per month administration fee with financial, clinical, and operational guarantees. And if we don’t reach the client’s goals, they pay less, guaranteed. The program takes the guess work out of PBM fees and maximizes proven strategies to improve health and drive better pharmacy care. This is a fundamental evolution of the pharmacy benefit. The ClearCareRx model is able to deliver a high level of transparency and better aligns value by focusing on total drug trend, patient specific outcomes, and operational excellence.
Going a step further, Express Scripts will also begin offering clients utilizing spread pricing models additional financial information to provide greater transparency into the services we provide. This enhanced reporting will make sure clients have a clear view of how the PBM is generating value and make them more informed about the tools available to manage costs.
These industry-first actions represent an increasing commitment to transparency, and they will help build trust with those who have questioned the ways the system operates.
Lowering Patient Out-of-Pocket Costs to Promote Affordability and Predictability at the Pharmacy Counter
A longstanding concern for patients and policymakers alike is affordability. Sky-high list prices for many prescription drugs continue to put a significant strain on families, taxpayers, and employers. The sweeping and often random range of drug prices coupled with rising deductibles provide another layer of complexity to the challenge. In response, Express Scripts is expanding our program that sets predictable copays for patients.
The Copay Assurance Plan will limit out-of-pocket costs, with customers of the program paying no more than $5 for generics and specialty generics, $25 for preferred brand drugs, and $45 for preferred specialty brand drugs every time they fill their prescription. The program immediately guarantees these lower out-of-pocket rates – consumers do not have to wait to meet any deductible levels. It is estimated that patients in this plan will be able to save an average of 27% on out-of-pocket costs – with substantially higher savings for customers who require life-sustaining medications to manage chronic or rare conditions, or customers fighting cancer or other disease that require complex specialty medications.
The Copay Assurance Plan will limit out-of-pocket costs, with customers of the program paying no more than $5 for generics and specialty generics, $25 for preferred brand drugs, and $45 for preferred specialty brand drugs.
With this plan, patients will know what they owe at the pharmacy counter. And they can have confidence that no matter how high the list price of a medication, they are shielded from these excessive costs that pharmaceutical manufacturers charge.
The Copay Assurance Plan builds on the success of – and aggressively expands – the Patient Assurance Program, which created tremendous savings and improved health outcomes for patients with diabetes, to provide predictability to millions more patients managing other health conditions. Within two years, we’ve achieved more than $45M in savings on insulin and $135M in savings on other diabetes treatments for consumers through our Patient Assurance Program.
You can read more about all the new programs announced by Express Scripts here.
What this means for policymakers
Taken together, these changes demonstrate how pharmacy benefits can work better. They are an ambitious effort to show that private sector innovations alone can meaningfully move the system forward for patients and others we serve. This effort also helps answer questions and addresses some of the key issues that policymakers and other stakeholders have raised about PBMs. Affordability, transparency, and simplicity are all strengthened as a result.
The programs set a new standard. Express Scripts is eager to work with policymakers to help them better understand how these changes improve the system and directly address priority issues.
It remains important that any policy solutions advance the continued use of private sector tools such as these, while not eliminating or restricting our ability to negotiate lower overall costs.
Pharmacy benefit companies have long been an important part of the solution to the challenge of high drug prices. This evolution in the business model continues to put PBMs on the side of patients and those who hire us that want lower costs and a healthier workforce. That’s what’s possible in pharmacy benefits.