4 Truths About PBMs: Driving Prescription Drug Affordability and Access

Here are the facts about the role that pharmacy benefit managers (PBM) play in driving prescription drug affordability and access.

Pharmacy benefit managers (PBMs) are a key part of the health care system, working with health plans and the employers who provide health benefits to their employees to help drive down the prices of prescription drugs. Drug spending – which is primarily driven by high-cost specialty drugs – continues to grow, totaling $301 billion in 2021, which is up 43% since 2016.

Research finds that PBMs can save payers and consumers $654 billion in prescription drug costs between 2016 and 2025 while playing a key role in expanding access to life-saving drugs.

“Not only do PBMs negotiate better net prices from drug manufacturers and pharmacies, they also reduce waste, improve medication adherence, encourage the use of generics and affordable brands, offer more convenient delivery, and drive quality rather than quantity of care,” said Adam Kautzner, President of Express Scripts, the PBM division of Evernorth Health Services. “The cost savings that come from PBMs are critically important to more than 266 million patients across the United States.”

Here are some facts about the role that PBMs play in driving prescription drug affordability and access.

PBMs Offer Stability in a Time of Uncertainty by Driving Down Costs for Consumers

In today’s economic environment, the average American household is spending almost $445 a month more for consumer goods than a year ago. Recognizing the important role that prescription drug affordability plays in access and in improving health outcomes, Express Scripts has introduced a new and innovative solution, the Copay Assurance Program, capping out-of-pocket costs for people whohave employer-sponsored health insurance.

This means customers of the program will pay 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 a prescription. The program will immediately guarantee these lower out-of-pocket rates – customers will not have to wait to meet any deductible levels. Members can save more than 25% at the pharmacy counter.


Capping Out-of-Pocket Costs for All Medications

Early pilots of the program show that Copay Assurance is proven to:

  • Reduce abandonment: For patients with a copay less than $40, the rate of abandonment is much lower than the average (38%).
  • Increase adherence: Utilization increased by 10% when compared to non-participating clients.
  • Reduce total medical costs: Our program showed adherence improvement drives significant reduction in total medical costs (15.9%–16.3% change)

PBMs Have Transparent Business Practices

There is a common misconception that PBMs aren’t transparent in their business practices. But that is not the case. To demonstrate our commitment to transparency, for example, Express Scripts has developed a transparent economic model for employer, health plan, and government employer clients by providing clear and predictable costs for prescription drug benefits.

Through the new program, called ClearCareRX, clients pay exactly what Express Scripts pays pharmacies for each prescription. Additionally, clients receive 100% of drug rebates that Express Scripts obtains by negotiating with pharmaceutical companies. Payers are charged one simple fee to cover the administration of pharmacy benefits, PBM product services, reporting, and analytics, keeping Express Scripts accountable to clinical and financial performance measures, including improvements in drug performance, adherence, and overall patient outcomes.

Clients Receive the Full Amount of Drug Rebates

We first piloted the ClearCareRx transparent pricing model with employers and health plans covering nearly 500,000 people. Early results include:

Express Scripts has also announced measures to enhance its disclosure practices for added transparency. Starting in 2024, every prescription will include a digital pharmacy benefits statement for consumers, which will outline drug price information, out-of-pocket costs, and more. Express Scripts will also roll out a client-facing microsite that will be updated consistently with the latest in incremental disclosures and filings with the SEC.

PBMs Improve Population Health, Reduce Waste, and Increase Medication Adherence

Express Scripts processes more than 1 billion pharmacy claims annually, which provides unparalleled insight into what’s happening in the lives of patients in real time. Think about emerging cases of COVID-19, the flu, depression, or diabetes – the pharmacy benefit is the leading indicator of health, and our Express Scripts PBM team plays a crucial role in making sure that our benefits will help people live their healthiest lives.

PBMs harness real-time data, insights, and care management programs to help patients start and stay on the most effective treatments. Conditions like depression and diabetes, for example, are often interconnected but treated in isolation. The Express Scripts PBM team helps us see a more complete picture and offer programs that go beyond pharmacy care alone.

In the U.S., 1% of drug costs are attributable to fraud, waste, and abuse, amounting to hundreds of millions of dollars in unnecessary costs. Express Scripts PBM uses drug utilization review to reduce waste and create unique programs, such as those using mobile applications and patient and provider interactions with specialized pharmacists, to help patients adhere safely to their prescription regimen.

Bringing Care Closer: Express Scripts' PBM Network

Pharmacy care is the most used health benefit – each member fills an average of 11 prescriptions each year. In addition to negotiating the price of medications, Express Scripts PBM partners with pharmacies across the U.S. to create our national network of more than 65,000 locations, which means nearly every member has an in-network retail pharmacy within a 15-minute drive of their home. Members can also get free delivery of medications to their homes in all 50 states. Today, more pharmacies are in our network than there are McDonalds and Starbucks in the U.S.

“Express Scripts exists to lower the cost of prescription drugs for the 100 million Americans we serve,” Kautzner said.Our clients – including health plans, employers, labor unions, government agencies, and others – choose to work with us because we deliver significant savings for them and their members. We provide choice and flexibility for our clients to make coverage options that support their unique member populations, and the savings we secure on their behalf are used to reduce costs for patients. We are the only entity in the U.S. health care system with the experience, focus, and resources to effectively do this.”