Major PBM to Offer Cost-Based Pricing Option for Prescription Medications

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ClearNetwork will be available for a plan sponsor’s list of covered generic, branded, and specialty drugs across 65,000 retail pharmacies in the Express Scripts network.

Prominent pharmacy benefit manager (PBM) Express Scripts has announced plans offer to a new pharmacy network option that is similar to the Mark Cuban Cost Plus Drugs model. The PBM said the Express Scripts ClearNetwork plan will provide employers with a simpler pricing structure.1

Image credit: adragan | stock.adobe.com

Image credit: adragan | stock.adobe.com

“We are constantly innovating to provide our clients with new options that meet their needs and enable them to build custom pharmacy benefits that best support their plans and members,” said Express Scripts President Adam Kautzner, PharmD, in a press release.1 “The Express Scripts ClearNetwork leverages our scale, relationships, and deep understanding of the pharmaceutical supply chain to create an easy-to-follow option for clients looking to simplify what they pay for prescription drugs, while supporting a seamless, convenient member experience.”

Express Scripts said ClearNetwork was designed for clients seeking a cost-based pricing option for prescription medications and pharmacy services and a "seamless experience for their employees and members."

ClearNetwork will use predictive acquisition cost, national average drug acquisition cost, or wholesale acquisition cost to project an individual drug’s acquisition cost. The plan will add a flat pharmacy fee and a second fee of 15%, which the PBM said will be transparent to clients and pharmacies. ClearNetwork will be available for a plan sponsor’s list of covered generic, branded, and specialty drugs across 65,000 retail pharmacies in the Express Scripts network.

Earlier this year, Express Scripts launched ClearCareRx, which seeks to provide a transparent economic model for prescription drug benefits.2 Through ClearCareRx, clients pay the amount Express Scripts pays pharmacies and receive 100% of rebates negotiated with pharmaceutical manufacturers, according to the PBM. Further, clients pay a fee for the administration of pharmacy benefits, PBM product services, reporting, and analytics, with guarantee measures and financial targets built into the program.

Express Scripts also launched a Copay Assurance plan this year that caps copays at no more than $5 for generics, $25 for preferred brand drugs, and $45 for preferred specialty brand drugs, which are applied before deductibles are met.2

Starting next year, the PBM will offer prescriptions that include a pharmacy benefits statement that shares drug price information and out-of-pocket costs, which will be implemented across all of its network pharmacies.

IQVIA has estimated that by 2025, 90% of all prescription fills will be for nonbranded generic drugs, accounting for just 7% of total drug spending in the country.3 This could have a significant impact on the specialty and specialty-lite drug marketplace, as many community pharmacies will only dispense generic drugs, as the average gross cost and reimbursement for prescription fills is estimated to fall. Further, 20% of Americans represent 70% of the spending on health conditions and 82% of prescription fills.4

As such, these new offerings from the PBM come during a renewed push by state and national legislators throughout the United States to regulate the practices of PBMs. Currently proposed legislation addresses issues such as the impact of PBMs on patient costs, incentives favoring high-priced drugs, and a greater need for transparency.

“This new model differs from other pricing options where Express Scripts negotiates discounts with pharmacies to meet guaranteed rates for clients,” Kautzner said in the release. “Express Scripts ClearNetwork is a simple pricing option that reinforces the value of our work to help consumers easily access the medications they need, while also shining a light on the root cause of high drug costs—drug manufacturers who set and raise prices.”

References

1. Express Scripts Introduces New Option to Give Clients Maximum Simplicity in Drug Pricing. Evernorth Health Services. News release. November 14, 2023. Accessed November 16, 2023. https://www.evernorth.com/articles/express-scripts-introduces-new-option-give-clients-maximum-simplicity-drug-pricing

2. Express Scripts Further Advances Transparency and Affordability for Consumers and Clients. Evernorth Health Services. News release. April 13, 2023. Accessed November 16, 2023. https://www.evernorth.com/article/pharmacy-benefits-management-pbm-affordability-transparency

3. The use of medicines in the U.S. 2022. IQVIA. April 21, 2022. Accessed November 16, 2023. https://www.iqvia.com/insights/the-iqvia-institute/reports/the-use-of-medicines-in-the-us-2022

4. Medicine use and spending in the U.S. IQVIA. May 9, 2019. Accessed November 16, 2023. https://www.iqvia.com/insights/the-iqvia-institute/reports/medicine-use-and-spending-in-the-us-a-review-of-2018-and-outlook-to-2023

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