Keeping Copays Affordable

Some pharmacy plans require their patients to pay a full copayment for a prescription drug even though a retail pharmacy’s price for the drug may be less costly than their copayment under their pharmacy benefit. And then they require the pharmacy to return the difference between the copay amount and the price for the drug back to them. We do not engage in or support this anti-patient practice, sometimes called a “copay clawback,” which frustrates both patients and pharmacists.

At Express Scripts, we believe our members absolutely must have full line of sight as to what a drug will cost them, and should know if there are opportunities to decrease that cost. We also believe patients should always pay the lowest price possible, whether that is their plan’s copayment, or their pharmacy’s cost for the medication, sometimes known as the Usual and Customary (U&C) cost. That means no clawbacks.

Lowest Copay Always

Employers know lower copayments help their members stay on track with their prescription therapy, and do all they can to help keep these copays as low as possible. However, there are instances, particularly with low-cost generics, where a pharmacy’s price for a medication is less than a patient’s established copay.

In any instance when the price for a medication at a particular pharmacy is less than the copay associated with that formulary tier, our members pay the lower price while still achieving the benefit of our real-time clinical safety review of the medication.

Information Within Reach

Express Scripts members always have real-time access to their drug coverage information and copay amounts. This information is available to them during open enrollment, before they even become our member. And it remains easily accessible to them on our website and mobile app.

In short, our members will always know what their specific cost will be for a prescription, based on their individual plan design, copay structure or current deductible status, before they fill their prescription. The Express Scripts website and mobile app tells our members if a medication will cost less at a different nearby pharmacy, in a different pharmacy channel, or if there is a less expensive clinical alternative they can discuss with their doctor. If their pharmacy’s U&C cost for their medication is less than their copay, we tell them that, too.

We believe this information helps our members become conscientious healthcare consumers, putting them in the driver’s seat of their pharmacy decisions. For our members in a high deductible health plan, this information is critical to managing their healthcare budget.

As an independent pharmacy benefit manager, we are uniquely and completely aligned with the best interests of our clients and members. To us, putting medicine within reach requires delivering the lowest possible net cost and being clear on how we do so.