Analysis Shows How Insurers and Middlemen Drive Up Out-of-Pocket Costs for Patients at the Pharmacy

WASHINGTON, D.C. (November 15, 2022) – A new analysis of commercially insured patients taking brand medicines finds that patients with deductibles and coinsurance are paying significantly higher costs at the pharmacy than patients with copays.

Data analyzed by the sponsored health care data analytics firm IQVIA shows that in 2021, commercially insured patients with deductibles or coinsurance spent six times more out of pocket, on average, for their brand and generic medicines than those with only copays. Patients were also nearly four times more likely to abandon new brand medicines filled in a plan with a deductible compared to those with copays.

The analysis underscores how health plans and pharmacy benefit managers (PBMs) often require patients with deductibles or coinsurance to pay their out-of-pocket costs based on the full price of the medicine instead of the lower, negotiated price the insurer or PBM receives.

“No one should have to pay more for medicines just because insurance companies refuse to pass along the discounts they receive,” said PhRMA president and CEO Stephen J. Ubl. “This is more evidence that insurers are passing costs on to patients and providing less coverage in return. Health plans and PBMs have a responsibility to treat patients fairly, and they should be held accountable for tactics that force patients to leave their medicines at the pharmacy counter.”

Other key findings from the analysis show that many commercially insured patients taking one or more brand medicines in 2021 were exposed to high out-of-pocket costs at the pharmacy counter, including:

  • Patients filling a brand prescription in the deductible paid eight times more, on average, for their medicine than a patient filling a brand prescription with a copay.
  • Deductibles and coinsurance accounted for 60% of patients’ out-of-pocket spending on brand medicines. 
  • Insurers and PBMs subjected two-thirds of patients taking brand medicines to deductibles or coinsurance.
  • Patients using cost-sharing assistance from manufacturers to access their brand medicines reduced their annual out-of-pocket costs by nearly 60%, leading to average savings of nearly $500.

“With deductibles expected to go up next year for employees of small businesses, the challenges patients experience at the pharmacy will only get worse,” continued Ubl. “As long as policymakers give insurers and middlemen a free pass, patients will continue to pay more for their medicines than their insurer.” 

About PhRMA

The Pharmaceutical Research and Manufacturers of America (PhRMA) represents the country’s leading innovative biopharmaceutical research companies, which are devoted to discovering and developing medicines that enable patients to live longer, healthier and more productive lives. Over the last decade, PhRMA member companies have more than doubled their annual investment in the search for new treatments and cures, including nearly $101 billion in 2022 alone. 

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