Setting the Record Straight on Patient Cost Sharing

It seems that some have been tossing around the word fact lately when they really mean opinion. Facts are things that we have real evidence to support, not simply statements we want to be true. PBMs work to provide patients with affordable access to their prescription drugs: a true statement that is supported by the facts.

Prescription drug benefits provide affordable access to medication.


90% of prescriptions filled are for generic medications, and the average generic copay is $6.97.

The average out-of-pocket costs across all retail prescriptions have been declining each year: from $10.14 in 2016 down to $9.41 in 2021. 

Just nine-tenths of one percent of prescriptions filled in 2021 had final patient cost sharing that was greater than $125.

PBMs provide affordable access to prescription drugs for 266 million people every year, which is over 3.6 billion scripts filled annually. Without PBMs, the savings they negotiate, and prescription drug coverage, patients could pay list prices – sometimes breathtakingly high list prices – for their prescriptions.

PBMs have programs to help patients that face high cost sharing, including those in their deductible phase.


PBMs encouraged the Internal Revenue Service (IRS) to expand the list of preventive care for health savings account (HSA) participants to include many prescriptions for chronic conditions like asthma and heart disease. Preventive care prescriptions can be covered at no or low cost-sharing ahead of an enrollee meeting the deductible in high deductible health plans.

PBMs offer plan sponsors the option of zero or low cost sharing on many prescription drugs, including insulin.

High prescription drug co-insurance and deductible payments are due to high and rising list prices


Only drug manufacturers set and raise list prices. According to GoodRx: “Since 2014, all goods and services have increased in price by 21%, while prescription drugs have increased in [list] price by 35%.” Over 90% of the most popular brand drugs have increased in list price at least once since 2014.

“According to GoodRx Research, higher list prices are directly tied to higher costs for consumers.” – GoodRx Health

Patient payments within the deductible, cash prescription fills, and co-insurance are all based on manufacturer-set list prices. High list prices hurt patients who must pay these prices. If list prices were lower, out-of-pocket payments based on list prices would be lower and more affordable.