As drug makers issue more coupons to help consumers lower their costs, a new study finds that the companies providing prescription coverage are fighting back by refusing to cover more medicines. And the tactics underscore the jockeying for profits in the lucrative pharmaceutical industry.
Consider coupons. Over the past several years, drug makers have used these to entice consumers to fill their prescriptions, since coupons defray or eliminate copay costs. In 2009, coupons were available for fewer than 100 prescription medicines, but the number exceeded 700 by last year, according to the analysis released on Tuesday by the Tufts Center for the Study of Drug Development. The study was funded by Pfizer (PFE).
Drug makers contend coupons help consumers who might otherwise have difficulty affording their medicines as insurance requires them to shoulder a greater share of the cost. This “can be a real barrier to patient access to medicines, and coupons can help break that barrier down,” the Pharmaceutical Research and Manufacturers of America, the industry trade group, wrote in a 2012 blog post on its web site.
Studies have shown, however, that coupons are a mixed bag.
A 2013 analysis in The New England Journal of Medicine found that 62 percent of coupons were available for brand-name drugs for which lower-cost options existed. But a 2014 study in Health Affairs found coupons reduced consumer costs for expensive specialty drugs to less than $250 a month, suggesting patients may be less likely to forego their medications.
Pharmacy benefit managers, which negotiate deals with drug companies and manage lists of covered medicines called formularies, argue that coupons are a ruse. As Tufts notes, pharmacy benefit managers and insurers believe coupons are increasingly used by drug makers to negate the exclusion of certain drugs from formularies, and other efforts in order to weed out less effective drugs and to lower costs.
So over the last few years, the nation’s two largest pharmacy benefit managers have been excluding more drugs from their formularies. CVS (CVS) Caremark excluded 124 drugs in 2016, a 63 percent increase since 2014, while Express Scripts excluded 80 drugs in 2016, a 67 percent rise since 2014, according to Tufts. Significantly, coupons were available for more than 90 percent of the drugs that were excluded.
The move reflects rising prescription drug spending, which increased more than 8.5 percent last year. And IMS Health forecasts that spending on medicines in the United States will reach anywhere from $560 billion to $590 billion, a 34 percent increase in spending over 2015, after factoring rebates and discounts offered by drug makers to payers.
For this reason, Tufts expects pharmacy benefits managers and insurers to continue to exclude drugs in order to blunt the spending trend. “The leverage gained by pharmacy benefits manager, by way of exclusions, puts downward pressure on prices of (certain) drugs,” said Joshua Cohen, a health economist at Tufts who coauthored the analysis.
A CVS spokeswoman wrote us that using a “more selective formulary” that restricts medicines saved individuals $35 for each prescription, on average, and overall saved more than $6 billion since exclusions began in 2012. She added, though, that drugs removed from its formularies are not only due to cost, but also if they are clinically inferior.
However, the Tufts analysis looked at 14 drugs and found that some were excluded by CVS, but not by Express Scripts which, Cohen said, suggests that pharmacy benefits managers are making such decisions based on the rebates they receive from drug makers, not whether a drug was actually cost effective.
“While coupons could help cover drugs that are otherwise excluded from formularies, as long as most time and money goes to rebates in exchange for formulary coverage, they are no substitute for affordable access if you have a chronic disease,” said Robert Goldberg, cofounder of the Center for the Public Interest, a think tank that is backed, in part, by drug makers.