What Benefits Pros Must Know About Prescription Drug Pricing Right Now

By Miriam Paramore, Founder & CEO of RxUtility

There's never been more "transparency" in prescription drug pricing – and in some ways, plan sponsors have never been more confused. That's not a coincidence.

After 35 years in healthcare technology and drug pricing policy, I've watched every transparency initiative promise to finally make the system legible for employers.

And each time, the data got bigger, the reports got longer, and the fundamental question got harder to answer: are we actually paying the right price, and are our members getting a fair deal?

I recently joined Scripta Insights for a fireside chat, and that's exactly the tension we set out to unpack – because having access to data and being able to make confident, accurate decisions from it are two very different things.

Why “Transparent" Pricing Doesn't Mean Accurate Pricing

There's enormous pressure on the pharmacy supply chain right now, and a lot of political energy directed at the middlemen in drug pricing. Some of that attention is deserved. But here's the uncomfortable truth: transparency, as it's currently defined and marketed, is more "all hat and no cattle" than most plan sponsors realize.

Having access to more pricing data is not the same thing as having decision-ready pricing information. A contract that shows you the gross drug cost, or a report that lists AWP-based discounts, tells you something—but it doesn't tell you what your member is actually paying at the counter. It doesn't account for the manufacturer copay coupon that wiped out their cost share, or the cash-pay pathway they used outside your network entirely. It doesn't tell you whether the rebates you're owed are being passed through in full. And it doesn't tell you whether the price your plan is paying has any relationship to what the drug actually costs in the real market.

Transparency is a floor, not a ceiling. And right now, most plan sponsors are operating well below even that floor—because the data access they need is being blocked, obscured, or simply never provided.

The question isn't whether you have a transparent arrangement. The question is: can you actually see what's happening, and can you act on what you see?

Six Prices for the Same Drug: Where the Gaps Live

Let me give you an example of just how wide these pricing gaps have become. Take Zepbound, one of the GLP-1 weight loss medications.

If you ask how much it costs, the honest answer is: it depends.

• Pay cash at retail with no assistance? Over $1,000.

• Use insurance without a copay card? Somewhere in the $100–$300 range out-of-pocket.

• The government's new most-favored-nation pricing? About $346.

• Buy directly from the manufacturer? $300–$450 cash price.

• Your formulary doesn't cover it, but you find a discount card option? As low as $4.99.

• Your formulary does cover it, and you use a copay coupon? $25.

Six different prices. Same drug. Same patient. Same day.

How do you respond to that from the standpoint of being the plan sponsor? Do you know what your consumer or your member or your employee is paying? How do you know what they chose?

Most plan sponsors don't. And that's not a minor oversight – it's a structural gap that leads directly to missed savings opportunities on both sides of the equation.

When your members don't know cheaper pathways exist, they either overpay or abandon their medications entirely. When you, as the plan sponsor, don't know which pathway they're using, you can't design benefits that close the gap.

Those pricing gaps are where the money is. And right now, most of it is going uncaptured.

How Pricing Pathways Create a Wedge Between Employer Costs and Member Affordability

Here's where it gets really important for benefits strategy: the pricing pathway a member uses doesn't just affect what they pay. It affects what you pay – and the two often move in opposite directions.

A member paying $0 out-of-pocket for a $23,000-per-year specialty drug – because a manufacturer's copay coupon is covering their share – sounds like a win for that member. But the plan is still paying the full claim. And when you show that same member a clinically equivalent biosimilar at $1,000 per year, they have no incentive to switch. Their out-of-pocket cost would actually go up.

That's the misalignment at the heart of modern pharmacy benefits. The member's best price is not the plan sponsor's best price.

It shows up in other places, too. Think about the deductible phase: A patient on Eliquis (a common blood thinner) might be paying $600 out-of-pocket while they're still in their deductible. But once they've met it, the employer's net cost on the same drug might be $300, because of negotiated pricing that kicks in later. That means your sickest members – the ones who most need their medications and are hitting the pharmacy counter earliest in the year – are paying more than your plan pays once their costs are covered.

Point-of-service rebates are designed to address this, passing the discount to the patient at the point of purchase rather than routing it to the plan as a back-end payment. But implementation is inconsistent, and many plan sponsors don't even know whether their current arrangement includes it.

The same dynamic plays out with copay coupons and high-deductible plan design, with cash-pay programs and formulary coverage decisions, with specialty pharmacy routing and biosimilar uptake. Every pricing pathway creates a different split between what the employer pays and what the member pays. Understanding that split, and designing benefits to bring those two interests into alignment, is the actual work of modern pharmacy benefits management.

How Recent Regulatory Changes Shape Your Rx Strategy

Drug pricing reform has generated a lot of headlines, and plan sponsors are right to pay attention. But it's important to be clear-eyed about what's actually changed versus what's still on the way.

The laws are on the books. The most-favored-nation pricing provisions, the Medicare drug negotiation provisions under the Inflation Reduction Act, the transparency requirements for intermediaries – these are real. But most of them don't fully take effect until 2028 or 2029. And critically, many of these reforms apply to government programs like Medicare and Medicaid, not directly to the commercial employer market where most self-insured plan sponsors operate.

In the meantime, drug prices are continuing to increase. Last year, premium increases for employers were driven primarily by drug costs, not medical utilization. The rate of growth in drug spend is outpacing medical spend – and that trend isn't going to reverse itself just because legislation passed in Washington.

What the regulatory environment has done is accelerate the proliferation of alternative pricing pathways: direct-to-consumer programs from manufacturers, new government reference price benchmarks, and expanded access to cash-pay platforms. These create new opportunities, but only for plan sponsors who are actively paying attention and structuring their benefits to take advantage of them. A passive "wait for the reforms to kick in" approach isn't a strategy. It's a gap year that costs you real money.

The honest message here is: regulatory change is slow, and it won't solve your pharmacy cost problem on your timeline. What's happening right now in the market—the new pricing pathways, the affordability tools, the clinical alternatives—that's where your leverage lives today.

What Employers Should Do to Improve Pricing Accuracy and Decision Confidence

The plan sponsors who are getting this right aren't waiting for the system to fix itself. They're doing a few specific things that set them apart:

They're looking at the full picture of what their members are actually paying. Not just what the plan pays, but what the individual employee is paying – and whether that's creating barriers to adherence or driving members toward higher-cost pathways.

They're proactively surfacing affordability options before members hit the pharmacy counter. I worked with one plan sponsor during an open enrollment period, when they were making formulary changes, and they used pricing data the way it's meant to be used. Instead of waiting for members to discover at the pharmacy that their drug was no longer covered, they proactively reached out with information about coupon availability and alternative coverage options.

They're aligning benefit design with actual price reality. When a member is paying $0 for a $23,000 drug because of a copay coupon, but would have a cost share on a $1,000 biosimilar, smart plan sponsors are restructuring the incentive. That might mean covering the biosimilar at zero cost share, or offering a direct financial incentive to at least consider the alternative. The goal isn't to take away choice – it's to make sure the incentive structure reflects what's actually in both the member's and the plan's best interest.

They're insisting on data access, not just data delivery. There's a meaningful difference between receiving a quarterly report and having the ability to actually dig into claim-level detail to understand what's driving cost. Leading organizations are insisting on the latter—and partnering with vendors who can help them interpret what they find.

Nearly 1,300 branded medications have manufacturer copay coupons – representing roughly $30 billion in potential consumer savings per year – and fewer than 10% are being used. That's not a patient behavior problem. That's a knowledge and distribution problem that engaged plan sponsors can solve right now, without waiting for any regulatory change to take effect.

Finding a Path Forward

The prescription drug pricing system is not going to fix itself. Regulatory reform is moving in the right direction, but it's incremental, it's slow, and much of it doesn't reach the commercial market directly. In the meantime, the gap between what your plan pays, what your members pay, and what those medications actually cost in the real market continues to widen.

The path forward isn't about finding someone to blame in the supply chain. It's about understanding the system well enough to work within it strategically – and making sure that both you and your members have the contextual, accurate, decision-ready information needed to act.

Together with Scripta, we want that drug pricing information to be trustworthy, accessible, and actionable – for the plan sponsors managing total cost, and for the individual standing at the pharmacy counter.

"We want everyone to be helped."

That's the goal. And with the right partners, the right data, and the right benefit design, it's within reach.

Miriam Paramore is the Founder and CEO of RxUtility, a prescription affordability platform that aggregates real-time cash prices and pharmaceutical manufacturer copay coupons across every drug and pharmacy in the U.S. She has spent more than 35 years at the intersection of healthcare technology, drug pricing, and policy.