Updated: November 19, 2024
Protecting patients from higher insulin prices
On November 19, 2024, Express Scripts sued the Federal Trade Commission to stop the Commission’s unfair and unconstitutional attempt to restrict the ability of PBMs to do their job: negotiating lower drug costs for patients.
The Federal Trade Commission’s allegations about PBMs and insulin are detached from reality – and go against decades of prior FTC findings by administrations from both political parties. If the Commission is successful in blocking our efforts to support patients and those who provide them with their healthcare plans, every American who relies on their health plan for accessible and affordable drugs – including insulin – will be harmed.
Read Express Scripts’ legal complaint
Our actions have ensured that patients living with diabetes have greater access to more affordable prescriptions, including insulins. In fact:
- The average out-of-pocket cost for insulin for Express Scripts members has decreased by 43% over the past decade.
- In 2019, long before the government acted, Express Scripts was the first to cap patient out-of-pocket costs for insulin medications at $25 for a 30-day supply.
- On average, our members pay only $22.78 for a 30-day supply of insulin.
And because diabetes management doesn’t always require insulin, particularly for Type 2 diabetes, we also expanded our Patient Assurance Program to include other non-insulin diabetes treatments, capping out of pocket costs at $25 for up to a 34-day supply
In targeting PBMs, the Commission is attacking the one critical element of the drug supply chain that lowers net drug costs for employers, labor unions and the government itself.
The FTC was created to be bipartisan, independent, and objective, and for more than 100 years, the FTC has fought to protect consumers and promote competition. Today’s FTC has turned its back on that legacy.
- The FTC has abandoned the “consumer welfare standard” and moved away from its statutory mission to protect consumers from harm.
The Commission has become focused on targeting and trying to take down politically disfavored companies, rather than following established law that promotes the best interests of the consumer. - Political bias – not facts – is driving the FTC’s campaign against PBMs that intentionally misrepresents how drug pricing and prescription drug benefits work.
The allegations by the FTC also overturn decades of prior FTC research under administrations from both political parties affirming the value that PBMs provide. Chair Khan’s actions and prior statements clearly demonstrate this bias. - The FTC is also using its in-house “kangaroo court” to reach a predetermined outcome, violating the due process clause of the Constitution in its actions.
The FTC is applying a highly dubious and novel legal theory for its action, not alleging any antitrust violations or collusion – the major basis of its authority – but rather claiming that PBM business practices are somehow “unfair” and therefore unlawful.
Furthermore, the FTC is stacking the deck, litigating the action not in open Court before an independent judge but in its own forum where it is the accuser, judge, and jury. Although the FTC has the authority to bring this case in open Court, it chose not to because its claims are weak and it wants home-court advantage.
Like the biased and misleading FTC 6(b) Report issued earlier this summer, the action filed by the FTC related to insulin is demonstrably baseless. We are deeply concerned that the FTC, a government agency funded by tax-payer dollars, continues to get an important issue such as drug pricing so irresponsibly wrong.
In the unlikely event that the FTC is successful in its action and forces PBMs to include drugs on formulary even if they result in higher net costs for plan sponsors and regardless of whether they are clinically necessary, the FTC will drive drug prices higher in this country – hurting consumers and those who provide their prescription drug benefits, including employers, labor unions, and the federal government itself.
We do not believe the FTC should be in the business of increasing drug prices.
In this action, the FTC has made more unsubstantiated assertions and seeks to advance a false narrative about the PBM industry, and we are compelled to rebut them yet again with substantiated data and evidence.
Here are the objective facts about how PBMs lower the cost of insulin:
1. Over the last decade, Express Scripts has saved plan sponsors and their members billions of dollars by lowering the net cost of drugs, including insulin, as well as lowering out-of-pocket spending.
2. Express Scripts negotiates with pharmaceutical manufacturers for the lowest net cost for drugs, including insulin.
Express Scripts helps ensure 3 in 4 members spend less than $100 a year out-of-pocket for all of their prescriptions.
For example, Lantus is an insulin that is used once daily to manage blood glucose. In 2021, it had a retail price of ~$510 for a pack of 5 pens. That same year, when several biosimilars for Lantus hit the market, our clinical teams evaluated the benefits provided by each and determined that Semglee, the first interchangeable biosimilar option, would be our preferred, recommended solution on our National Preferred Formulary. That recommendation saved our clients an estimated $20 million in 2022 alone. This move was commended by FTC Commissioner Slaughter, who highlighted Express Scripts as an example of a PBM that does not “exclude more affordable alternatives to brand medications.”
3. Express Scripts was the first to cap out-of-pocket costs for insulin medications at $25 for a 30-day supply in 2019, long before the government took action.
On average, members in plans that use Express Scripts only pay $22.78 for a 30-day supply of insulin, either through our Patient Assurance Program, their plan sponsor’s benefit design, or both.
Through our Patient Assurance Program (PAP), we capped the out-of-pocket costs on insulin and non-insulin diabetes treatments at $25 for up to a 34-day supply – that’s less on average than most caps mandated by federal and state laws.
As a result, our Patient Assurance Program delivered more than $200 million in total patient savings for insulin and other diabetes medications at the pharmacy counter since 2020 and more than $244 million in medical cost savings due to increased adherence and improved outcomes in 2022 alone— saving each patient nearly $2,500 on average.
For patients, their total diabetes-related cost share—inclusive of medical and pharmacy costs – has decreased by half (50.5%) since 2020.
4. The FTC’s action ignores that Express Scripts has for years taken steps to include low-list price insulins on its standard formularies and continues to expand access to these drugs.
The action seeks to force Express Scripts to prefer or co-prefer low-list price drugs that Express Scripts already prefers or co-prefers. Express Scripts already includes low-list price insulin alternatives on its largest standard formulary, and for 2025, Express Scripts has already determined to co-prefer additional insulins because doing so will result in lower net costs for plan sponsors. But the FTC did not even bother to check these facts. It’s also concerning the FTC would demand an approach regardless of net cost – which could have a negative impact on consumers and plan sponsors. FTC’s cavalier approach to the actual facts on insulin and to the actual net cost of drugs is irresponsible.
5. PBMs increase adherence and improve health outcomes for diabetes patients.
Beyond our efforts to lower net costs for our clients, Express Scripts drives improved patient health outcomes by leveraging clinical expertise and programs that help people get and stay on the medications they need.
For example, patients enrolled in our Patient Assurance Program for diabetes have seen not only substantial savings, but 30% greater adherence to their treatment.
6. Express Scripts and other PBMs only exist because they provide real value, savings and drive lower net drug costs for plan sponsors.
Our clients would not work with us if we didn’t provide immense value.
In 2023 alone, Express Scripts delivered approximately $38 billion in client savings.
Rebate negotiations have resulted in significant reductions of the price paid by plan sponsors for drugs, through the payment of rebates and fees to plan sponsors. The data shows that Express Scripts passes on more than 95% of the rebates and fees received to plan sponsors.
As the Senate Finance Committee report on insulin pricing stated, many clients “use rebates to lower premiums, lower cost-sharing, or fund wellness programs for beneficiaries.”
