Your medicine should fight for you.
You shouldn’t have to fight for your medicine.

We understand that many patients struggle to access the medicine they need, and have important questions about the cost of their medicines. We want to help find answers.

Here, we take a broad look at this complex issue to explore the recent decline in medicine cost growth, the rising cost of chronic disease, how insurers cover medicine, the role of middlemen and what our industry can do to make medicine more affordable for patients.

For the last few years, our Let's Talk About Cost campaign has sought to answer common cost questions and advance a dialogue on how we can make medicines more affordable for patients. That's why we launched a television advertisement to generate more conversation about solutions to the challenges patients face affording their medicines.

  • 1)
    Who decides what you pay for your medicine?
    Your pharmacy
    The biopharmaceutical company
    Your health insurer — Biopharmaceutical companies do set the initial list price for a brand medicine, but ultimately your insurer determines how much of that cost is rebated back to you. More ►
    The government
  • 2)
    Insurers negotiate discounts on medicines, but what percentage of insured patients pay out of pocket based on the list price?
    5%
    52% — More than half of all commercially insured patients' out-of-pocket spending is based on the full list price of their medicines. More ►
    15%
    0%
  • 3)
    What are the majority of health care dollars spent on?
    Prescription medications
    Hospital visits
    Dental services
    Chronic disease — 90 cents of every dollar spent on health care is used to treat people with one or more chronic condition. More ►
  • 4)
    How do pharmacy benefit managers - middlemen in the biopharmaceutical supply chain - currently get paid?
    As a percent of the list price of a medicine — This creates a system where middlemen make more money when your medicine prices increase. Patients with high-deductible health plans or coinsurance do not always realize the benefit of growing discounts and rebates because their out-of-pocket costs are often based on the medicine’s undiscounted list price. Reforms to prevent pharmacy benefit managers and others in the supply chain from being paid off the list price of a medicine can fix broken incentives and make the system work better for patients. More ►
    A fee based on the value their services provide
    As a percent of what patients pay at the pharmacy
  • 5)
    Does my coupon count toward my deductible and out-of-pocket maximum?
    Yes
    No
    It depends — Normally, cost sharing paid by copay coupons count toward a patient’s deductible and out-of-pocket maximum. However, many insurers and pharmacy benefit managers are implementing copay accumulator programs that change how copay assistance for some medicines applies to patient cost sharing. When this tactic is applied, copay coupons do not count toward a patient’s deductible or out-of-pocket maximum. More ►
  • 6)
    How much did spending on medicines grow in 2018?
    20%
    15%
    5%
    0.3% — In 2018, spending on prices for brand medicines grew just 0.3% after factoring in discounts and rebates at the slowest rate in years, according to one of the nation's largest PBMs. More ►
  • 7)
    How much are hospitals marking up the cost of medicines?
    500% — Even after negotiations with payers, hospitals still receive nearly 2.5 times more than what they paid to acquire medicine. More ►
    25%
    100%
    10%
  • Score: 
    0/7
    Answers
    Q1)
    Who decides what you pay for your medicine?
    CORRECT ANSWER: Your health insurer -   More ►
    Q2)
    Insurers negotiate discounts on medicines, but what percentage of insured patients pay out of pocket based on the list price?
    CORRECT ANSWER: 52% -   More ►
    Q3)
    What are the majority of health care dollars spent on?
    CORRECT ANSWER: Chronic disease -   More ►
    Q4)
    How do pharmacy benefit managers - middlemen in the biopharmaceutical supply chain - currently get paid?
    CORRECT ANSWER: As a percent of the list price of a medicine -   More ►
    Q5)
    Does my coupon count toward my deductible and out-of-pocket maximum?
    CORRECT ANSWER: It depends -   More ►
    Q6)
    How much did spending on medicines grow in 2018?
    CORRECT ANSWER: 0.3% -   More ►
    Q7)
    How much are hospitals marking up the cost of medicines?
    CORRECT ANSWER: 500% -   More ►
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Who decides what I pay for my medicine?

While biopharmaceutical companies set the list price for a brand medicine, 40 percent of a medicine's list price is given as a rebate or discount to the government and middlemen, like insurers and pharmacy benefit managers (PBMs). Insurers negotiate large rebates, but do not share these discounts with patients who pay a deductible or coinsurance -- a percentage of costs a patient is responsible for paying out of pocket -- for their medicine. Ultimately your insurer determines what you pay for your medicine out of pocket.

40%

of a medicine's list price is given as a rebate or discount to the government and middlemen

Why am I paying more than my insurer for my medicine?

Private payers reportedly receive rebates between 30 and 70 percent for medicines that treat a number of chronic conditions including diabetes, asthma, hepatitis C and high cholesterol. Yet, these negotiated discounts are not shared with patients who pay a deductible or a coinsurance -- a percentage of costs a patient is responsible for paying out of pocket -- for their medicine at the pharmacy. No patient should pay more for their medicine than their insurer.

50%

More than half of commercially insured patients’ out-of-pocket spending for brand medicines is based on the full list price

Why am I paying more than my insurer for my medicine?

Private payers reportedly receive rebates between 30 and 70 percent for medicines that treat a number of chronic conditions including diabetes, asthma, hepatitis C and high cholesterol. Yet, these negotiated discounts are not shared with patients who pay a deductible or a coinsurance -- a percentage of costs a patient is responsible for paying out of pocket -- for their medicine at the pharmacy. No patient should pay more for their medicine than their insurer.

What is the biggest driver of health care spending?

The biggest cost driver in our health care system is chronic disease. Patients with chronic diseases, like diabetes, account for 90 percent of all health care spending, and chronic disease is the leading cause of death and disability in the United States.

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Medicines are often the most cost-effective means of preventing and treating disease. Every additional dollar spent on medicines for adherent patients with ailments like congestive heart failure, high blood pressure, diabetes and high cholesterol generated $3 to $10 in savings on emergency room visits and inpatient hospitalizations. If medicines were used properly, the U.S. health care system could save $213 billion annually.

90%

of every dollar spent on health care is used to treat people with one or more chronic condition

Why are medicines less expensive in other countries?

The share of health care spending attributable to medicines in the United States is in line with that of other countries like Canada, France, Germany and Japan. Unlike foreign governments that often set prices and restrict coverage as a condition of entering the market, the United States relies on its competitive marketplace to control costs and provide patients with access to medicines far earlier.

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As a result, in the U.S. medicines are available almost immediately after approval. For example, Americans have access to new cancer medicines two years earlier, on average, than other wealthy countries. This is one reason why American patients have higher cancer survival rates than patients in several European countries.

14%

Spending on retail and physician-administered medicines represents 14% of U.S. health care spending

Why are medicines less expensive in other countries?

The share of health care spending attributable to medicines in the United States is in line with that of other countries like Canada, France, Germany and Japan. Unlike foreign governments that often set prices and restrict coverage as a condition of entering the market, the United States relies on its competitive marketplace to control costs and provide patients with access to medicines far earlier.

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As a result, in the U.S. medicines are available almost immediately after approval. For example, Americans have access to new cancer medicines two years earlier, on average, than other wealthy countries. This is one reason why American patients have higher cancer survival rates than patients in several European countries.

Who are pharmacy benefit managers?

Middlemen in the prescription drug supply chain called pharmacy benefit managers (PBMs) negotiate large rebates from biopharmaceutical companies on behalf of insurers and employers. But rather than getting paid based on the value their services provide, their compensation is tied to the list price of a medicine, in the form of retained rebates. They also charge fees to biopharmaceutical companies and health plans that are often based on list prices, and these fees nearly quadrupled between 2014 and 2016. This creates a system where middlemen make more money when your medicine prices increase.

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Over time, how we pay for medicines in the United States has evolved into a complex system of list prices, rebates and fees that move through an opaque supply chain. A medicine's rebate - rather than its actual price - often determines if it is covered or where it sits on a formulary. This creates an unfair system that incentivizes higher list prices and larger rebates. Reforms to prevent PBMs and others in the supply chain from being paid off the list price of a medicine can fix broken incentives and make the system work better for patients.

Middlemen Profit
Medicine Cost
Middlemen make more money when your medicine prices increase.

Why don’t middlemen always let my copay coupons count toward my deductible?

In recent years, pharmacy benefit managers and insurers have been increasingly shifting more health care costs to patients. Since 2006, deductibles have increased almost 360 percent and there has been an 89 percent rise in what patients pay in coinsurance, which is a percentage of costs associated with their health care service or medicine. Coupon programs - offered by biopharmaceutical companies - provide a valuable source of assistance for many commercially insured patients who are facing rising out-of-pocket costs because of their insurance coverage.

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Unfortunately, many insurers and pharmacy benefit managers are implementing copay accumulator programs, changing how copay assistance for some medicines applies to patient cost sharing. These programs block copay coupons from being applied to deductibles and out-of-pocket maximums for some medicines, which over the course of the year leads to patients paying significantly more at the pharmacy.

360%

Approximately how much deductibles have increased since 2006

Why don’t middlemen always let my copay coupons count toward my deductible?

In recent years, pharmacy benefit managers and insurers have been increasingly shifting more health care costs to patients. Since 2006, deductibles have increased almost 360 percent and there has been an 89 percent rise in what patients pay in coinsurance, which is a percentage of costs associated with their health care service or medicine. Coupon programs - offered by biopharmaceutical companies - provide a valuable source of assistance for many commercially insured patients who are facing rising out-of-pocket costs because of their insurance coverage.

More +
Less +

Unfortunately, many insurers and pharmacy benefit managers are implementing copay accumulator programs, changing how copay assistance for some medicines applies to patient cost sharing. These programs block copay coupons from being applied to deductibles and out-of-pocket maximums for some medicines, which over the course of the year leads to patients paying significantly more at the pharmacy.

If medicine costs are growing more slowly, why doesn’t it feel that way?

New therapies are transforming care for patients fighting debilitating diseases like cancer, hepatitis C, high cholesterol and more. In the midst of all this progress, net prices for brand medicines grew just 0.3 percent in 2018, less than the rate of inflation. And spending on medicines for one of the nation’s largest PBMs grew just 0.4 percent last year.

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Unfortunately, it doesn't feel this way for patients. Insurers are increasingly using high deductibles, which result in patients paying the full list price for their medicines, even if their insurers receive significant discounts. And middlemen, like pharmacy benefit managers and insurers, have been shifting more of the costs of health care to patients for years – with deductibles increasing 350 percent since 2006.

0.3%

The amount spending on medicines grew in 2018 according to one of the nation's largest PBMs

How much are hospitals marking up the cost of medicines?

Hospitals mark up medicine prices nearly 500 percent, and one in every five hospitals marks up the price of medicine by at least 700 percent. For a medicine with a list price of $150, this markup could cost patients up to $1,050. Insurers pay for medicines administered in hospital outpatient settings differently than those purchased at a pharmacy. Even after negotiations with commercial payers, hospitals still receive nearly 2.5 times what they paid to acquire the medicine. For example, many cancer treatments are provided in a hospital facility where the hospital purchases the medicine directly and is then reimbursed by the patient's insurer—often at a steep markup. Importantly, this is a conservative estimate as it does not take into account the impact of the 340B program. The 340B program was designed to increase access to medicines for vulnerable or uninsured patients through safety-net facilities, but all signs point to 340B doing the opposite.

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Unfortunately, many hospitals have taken advantage of the program without ensuring patients benefit. Current regulations enable participating 340B hospitals to make a profit by dispensing medicines that were obtained at a discounted rate, requesting reimbursement at the non-discounted rate and then pocketing the difference between the two rates. Over the years, the 340B program has grown and grown, with hospitals bringing in more and more 340B revenue, yet charity care rates and uncompensated care rates have all declined.

2.5x

Hospitals receive 2.5 times what
they paid to acquire medicine (after price negotiations)

How much are hospitals marking up the cost of medicines?

Hospitals mark up medicine prices nearly 500 percent, and one in every five hospitals marks up the price of medicine by at least 700 percent. For a medicine with a list price of $150, this markup could cost patients up to $1,050. Insurers pay for medicines administered in hospital outpatient settings differently than those purchased at a pharmacy. Even after negotiations with commercial payers, hospitals still receive nearly 2.5 times what they paid to acquire the medicine. For example, many cancer treatments are provided in a hospital facility where the hospital purchases the medicine directly and is then reimbursed by the patient's insurer—often at a steep markup. Importantly, this is a conservative estimate as it does not take into account the impact of the 340B program. The 340B program was designed to increase access to medicines for vulnerable or uninsured patients through safety-net facilities, but all signs point to 340B doing the opposite.

More +
Less +

Unfortunately, many hospitals have taken advantage of the program without ensuring patients benefit. Current regulations enable participating 340B hospitals to make a profit by dispensing medicines that were obtained at a discounted rate, requesting reimbursement at the non-discounted rate and then pocketing the difference between the two rates. Over the years, the 340B program has grown and grown, with hospitals bringing in more and more 340B revenue, yet charity care rates and uncompensated care rates have all declined.

Why are patients paying so much for insulin?

Unfortunately, too many patients struggle to afford their insulin at the pharmacy counter. Over the last decade, new innovations have transformed how we treat diabetes. But in that same time period, insurers have shifted costs to patients, making them pay based on a medicine's undiscounted list price. And too often, savings negotiated by insurance companies are not shared directly with patients.

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Prices after discounts and rebates for the most commonly used insulin classes are declining. That is because middlemen negotiate deep discounts which can lower the price of insulin by 70 percent or more. However, middlemen - like pharmacy benefit managers and insurers - don't always share these savings with patients.

70%

Amount discounts can lower the price of insulin, according to industry analysts

How can we make medicines more affordable for patients?

Too often patients have to fight to access breakthrough medicines that are revolutionizing how we fight disease. We can improve patient access and affordability by changing the incentives in the supply chain so that more of the negotiated rebates and discounts are used to lower costs for patients at the pharmacy counter.

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We also need to delink supply chain payments from the list price of a medicine. Biopharmaceutical companies are also working with insurers to develop innovative and flexible ways to pay for medicines that focus on results, lower out-of-pocket costs and enable patients to access the right treatments the first time.

Biopharma
Insurers
Results-based contracting allows biopharmaceutical companies and insurers to share financial risk.

How can we make medicines more affordable for patients?

Too often patients have to fight to access breakthrough medicines that are revolutionizing how we fight disease. We can improve patient access and affordability by changing the incentives in the supply chain so that more of the negotiated rebates and discounts are used to lower costs for patients at the pharmacy counter.

More +
Less +

We also need to delink supply chain payments from the list price of a medicine. Biopharmaceutical companies are also working with insurers to develop innovative and flexible ways to pay for medicines that focus on results, lower out-of-pocket costs and enable patients to access the right treatments the first time.

Learn More About
Your Medicine Costs

To provide patients with more transparency about medicine costs, the biopharmaceutical industry voluntarily directs patients to links to cost information in their direct-to-consumer (DTC) television advertising. The industry also launched the Medicine Assistance Tool, or MAT, to provide these links referenced in DTC television advertising and help patients connect to financial assistance programs. These are just a few of the ways the biopharmaceutical industry is continuing to work to ensure patients have more transparency about medicine costs.

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