Express Scripts rolls out new copay caps, PBM model with focus on transparency

Pharmacy benefit management giant Express Scripts is rolling out multiple new programs in a bid to evolve its model to be more transparent and predictable for patients and plan sponsors.

The company, a subsidiary of Cigna's Evernorth, unveiled two new programs Thursday morning that serve as the cornerstone of the refresh. The first, called Copay Assurance, caps the costs of generic drugs and preferred branded or specialty drugs for members enrolled in the program.

The initiative builds on the PBM's Patient Assurance program, which was launched several years ago to cap the cost of insulin and other diabetes treatments at $25 for a 30-day supply. Under Copay Assurance, generic drugs are capped at $5 for a 30-day supply, preferred brand-name drugs are capped at $25, and preferred specialty brand drugs are capped at $45.

The new solutions will be available beginning this summer.

Express Scripts President Adam Kautzner told Fierce Healthcare that addressing the affordability of drugs and making those costs more predictable improves utilization and adherence, which leads to better patient outcomes.

Patient Assurance saved patients more than $45 million in two years. Through Patient Assurance, Cigna found that patients with a copayment of $40 or less were far less likely to abandon their medications, and utilization increased by 10%.

As the team looked to build on that success, Kautzner said it was critical to ensure that the new offering extended to specialty drugs. The cost of these therapies is on the rise, and it's a huge pain point for both patients and plan sponsors like employers.

"That was absolutely a focus for us," he said. "It can't just be about traditional medications."

Express Scripts expects that members can save more than 25% at the pharmacy counter on their prescriptions. The program also simplifies communications and explanation of benefits and ensures members do not have to price shop outside of their coverage to use discount or copay cards for their medications.

In addition, the PBM is working with its employer and payer clients to offer consultative solutions to make it easier for them to manage costs, including broad lists of preventive drugs under coverage, lower premiums and deductibles as well as higher health savings account contributions.

The second offering unveiled Thursday by the PBM is called ClearCareRx, and it aims to offer a simpler, more transparent PBM contracting model to customers. Plan sponsors that sign on with ClearCareRx will pay for a drug what Express Scripts pays the pharmacy, and 100% of rebates are passed back to the payer.

Plan sponsors will also pay Express Scripts a streamlined per-member per-month fee for its services, and the PBM will set plan-specific targets for improving health and value. If those goals aren't met, Express Scripts said the fees will be less.

Kautzner said ClearCareRx was built on the idea of keeping the PBM accountable for providing high-quality service.

"It keeps us accountable and ensures we’re delivering the best possible care and drug trend management," he said.

PBMs have been under the microscope for the lack of transparency around their pricing models, and Kautzner acknowledged that Express Scripts has heard feedback from patients and lawmakers in this area.

Randy Rutta, CEO of the National Health Council, which includes multiple patient advocacy groups, told Fierce Healthcare that if the model proves effective, it could pave a path for others in the industry to follow as they aim to navigate the political pushback.

He said Express Scripts is stepping into "somewhat unknown territory" with the new models.

"As we see this plan take effect, hopefully it will have exactly the dividends that Cigna envisions," he said.

In addition to the two new platform offerings, Express Scripts said it plans to launch other programs that aim to boost transparency around drug pricing and the models it uses to manage costs. For one, beginning in 2024, patients can access an easy-to-understand digital benefits statement with every prescription.

These digital tools will be rolled out across all 65,000 pharmacies in Express Scripts' network as well as for Accredo specialty pharmacy and Express Scripts Pharmacy.

The PBM is also going to provide additional clarity around spread pricing arrangements, which have been a central concern in the conversation around these companies and how they operate. Express Scripts said, beginning with the 2023 plan year, it will provide enhanced financial and fee disclosure information to clients who choose a spread pricing arrangement.

Kautzner said that it will look essentially like a "chargemaster" for spread pricing models and will outline what plans are paying for any services involved.

"We want everyone to feel comfortable with what we’re providing, and that’s historically something that PBMs haven’t done," he said, "and so we’re going to take a step forward."