Uncover six common misconceptions about self-pay pharmacies and learn why pharmacy benefit managers (PBMs) often provide more affordable, accessible, and clinically appropriate care.
Cash pharmacies like “Cost Plus Drugs” have grown in popularity in recent years as more people choose high deductible health plans and take their health care online. While direct-to-consumer pharmacies play an important role for some patients, their value compared to traditional benefits is often overstated. This article explores six common myths regarding the relative value of cash pharmacies and shares the facts about their limitations.
Myth 1: Cash pharmacies are cheaper for patients than a prescription drug benefit
Filling prescriptions through cash pharmacies is often more expensive for patients than using their pharmacy benefits. When making a direct comparison, a recent Journal of the American Medical Association (JAMA) study found that, in 2023, only 12% of generic prescriptions would have been cheaper for patients from Cost Plus Drugs as compared to processing through traditional pharmacy benefits. Additionally, when looking at Cost Plus Drugs’ 15% markup, $5 dispensing fee, and $5 shipping charge for its available drugs, Express Scripts’ members pay less for those same drugs 94% of the time.1 These findings suggest that pharmacy benefits are the better choice for patient cost savings in most cases.
Myth 2: Cash pharmacies provide the same access to medications as a prescription drug benefit
Cash pharmacies cannot match the breadth of the formulary offered by typical PBMs. Their offerings are limited. Express Scripts’ most popular formulary is carefully curated to ensure patients and providers have options to treat most health conditions. It covers more than 75,000 medications2 whereas cash pharmacies can only provide access to a fraction of that amount. For example, patients visiting the Cost Plus Drugs site can only select from approximately 3% of the drugs currently available on the market.3 In a side-by-side comparison, only two of the 25 specialty medications most commonly used by Express Scripts’ commercial members4 are available through Cost Plus Drugs.
Based on a comparison of data provided by Cost Plus Drugs on May 22, 2024, against third-party drug compendia.
Myth 3: There’s nothing special about specialty medications, and they should be available from any pharmacy.
Many specialty medications, crucial to patients managing complex conditions, require extensive clinical support. Cash pharmacies are not equipped to provide this level of care – which could include support from specialized pharmacists, nurses, dieticians, social workers and more – for specialty treatment. Many PBMs, including Express Scripts, utilize a specialty care model that employs extensive clinical care management to closely monitor treatment and make sure patients are supported and are using these complex medications correctly and safely. In fact, Express Scripts’ model includes drug utilization management programs that help ensure the safest, most cost-effective specialty drug is chosen.
For example, Express Scripts offers guidance to doctors about conducting recommended genomic testing to identify patients with advanced non-small cell lung cancer (NSCLC) who might benefit from targeted specialty therapies. Such therapies are generally more effective and less harmful than traditional chemotherapy for patients with certain cancer cell mutations. Express Scripts’ efforts led to increased testing rates from 62% in 2019 to 97% in 2020, as well as more NSCLC patients being matched to a more appropriate targeted therapy as their first-line treatment. This resulted in five-year survival rates ranging from 15% to 50%, compared to 9% for other advanced NSCLC patients.
Myth 4: Cash pharmacies provide more convenient access to medications than a prescription drug benefit
Cash pharmacies often have limited reach as they tend to have relatively few pharmacy locations dispensing these drugs as compared to PBMs. For example, Express Scripts’ network of over 64,000 pharmacies is 10 times larger than Cost Plus Drugs’ network,5 and includes home delivery, local community pharmacies, and regional and chain pharmacies. With a pharmacy network built with the patient in mind, nearly every Express Scripts member is within a 15-minute drive of an in-network retail pharmacy, including more than 20,000 independent pharmacies across the country.6
Myth 5: The cash-pay model ensures safe and clinically appropriate care
One of the biggest and costliest challenges in managing the rise of chronic conditions is ensuring patients receive and use the medications they need. While both cash pharmacies and Express Scripts perform safety checks, Express Scripts employs a more robust system by conducting thousands of safety checks to prevent dangerous drug interactions before dispensing each prescription.
Additionally, Express Scripts continues to help members manage their condition after a prescription is filled through comprehensive disease management, which includes condition-specific coaching, medication adherence tracking, and digital tools. This approach has led to:
Myth 6: Cash pharmacies are the best option for transparent prices.
Just as they would at a cash pharmacy, Express Scripts clients and members have a clear line of sight into pricing and contracting markups and fees, such as through its Benchmark Plus acquisition cost model.
Cash pharmacies tout transparency and cost effectiveness, but they can mislead insured patients into believing they’re saving more money than they actually are. For example, a Humira biosimilar from Cost Plus Drugs costs a patient approximately $600 out of pocket every month. A patient who utilizes their pharmacy benefit for a Humira biosimilar that has a similar out-of-pocket cost will also benefit from reaching their deductible sooner – ensuring they pay very little towards the cost of their medications once their deductible is reached. While cash pharmacies may benefit some patients in specific instances, they are rarely the best choice for insured patients living with chronic conditions that require long-term treatment.
Cash pharmacies have loudly declared themselves disruptors, which might appear appealing at first glance. However, they ultimately fall short in several key aspects of access, affordability, and support compared to the coverage provided by pharmacy benefit managers.
Click here to learn more about common misconceptions about PBMs.
1 Based on a comparison of data provided by Cost Plus Drugs on May 22, 2024, against Express Scripts’ Benchmark Plus network and third-party drug compendia.
2 Express Scripts. National Preferred Formulary, 2024.
3 Based on a comparison of data provided by Cost Plus Drugs on May 22, 2024, against third-party drug compendia.
4 Express Scripts. Top 25 specialty medications in commercialized population, based on utilization per member per month, through August 2024.
5 Based on a comparison of data provided by Cost Plus Drugs on May 22, 2024, against third-party drug compendia.
6 Express Scripts. Pharmacy network data, 2024.