Some lawmakers favor laws that would limit patient cost-sharing for specialty drugs and not allow copays to be related to the drug’s price. However, when cost-sharing is tied to a drug’s price, drug makers have some incentive for restraint in pricing. Capping specialty cost-sharing would increase premiums, affect costs across multiple drug tiers, and result in more limited plan choices and formularies.
Drug companies use mechanisms that are marketed as ways to help patients pay for their brand name drugs, such as copay coupons and quick start programs, but these and other kickback schemes are actually designed to induce patients to ignore formularies, networks, and other tools created to make drug benefits more affordable. These programs can encourage patients to choose expensive brand drugs even though there may be more reasonable and equally effective options available.
In contrast, PBMs’ preferred pharmacy network drug plans offer patients and payers lower cost-sharing options. Patients appreciate low-premium, preferred network plans since they offer an abundance of pharmacy choices at lower costs.
Pharmacy Benefit Managers (PBMs): Generating Savings for Plan Sponsors and Consumers, Visante, 2016, PCMA sponsored