A growing number of health systems and insurers are starting to provide real-time drug pricing information to physicians to help patients avoid high prices at the pharmacy. Roughly 800 doctors are testing the Blue Shield of California drug pricing tool this year. Humana introduced its drug pricing tool to its network of doctors in 2015.
The pricing tools generally show how much patients can expect to pay out of pocket, based on their insurance and the pharmacy they choose. The doctor can also use the tools to find a cheaper alternative, when one is available, and start the process of getting authorization, if the insurer requires that.
Last month, the Centers for Medicare & Medicaid Services mandated that all Medicare drug plans embed such a tool in their doctors’ electronic prescribing system starting in 2021. Demetrios Kouzoukas, head of the Medicare program for CMS, said in a statement that he hopes the new drug mandate will spark the creation of a standard pricing tool that will work regardless of patient’s doctor or insurance.
The biggest barrier to a standard pricing tool is the pharmacy benefit managers, or PBMs. These are the middlemen who negotiate with drugmakers on the prices for medications and which ones the insurers will cover. Price negotiations among insurers, drugmakers, and middlemen are often highly competitive and secretive, so not all PBMs share their data on health plan enrollee costs. A tool’s usefulness is undermined when key PBMs are not included in the listings.
That all might be changing soon. There have been increasing calls to make drug prices more transparent and bring the shadow negotiations into the light. The soaring cost of drugs has been a main point in the national debate over revamping health care in the U.S. Each year, hundreds of thousands of prescriptions are abandoned at American pharmacies, often because of high prices. The National Council for Prescription Drug Programs, a nonprofit group that helps set guidelines for the pharmacy industry, has been working on criteria for a standard drug pricing tool.