Medication Affordability Depends on Total Price Transparency

There is a feeling of powerlessness and frustration that comes with putting your care in the hands of medical professionals and not knowing how much it will cost.

It’s a scenario I’m confronted with each time a Crohn’s disease flare-up triggers abdominal pain that is so severe, I need to go to the emergency department (ED) for relief. During one recent visit, a physician I hadn’t yet seen recommended a CT scan. “How much will that cost?” I asked a nurse, explaining that I’m on a high-deductible plan. No one could tell me. 

After about six hours of waiting and undergoing one other test for which I did not know the cost, I opted to go home instead. Crohn’s is a disease I’ll live with all my life. I know no matter how well I try to control it, there are times when a bad flare up could lead to internal bleeding, putting me back in the ED again. But that particular day, the weight of an unknown expense on top of the long wait I had already experienced just wasn’t worth it.

As any consumer can attest, you don’t need to go to the ED to encounter a price transparency obstacle in healthcare. Most of us face this challenge at a more familiar point of care — the pharmacy counter.

It’s time to solve the medication affordability conundrum with a practical fix. We must use technology to put complete price transparency in the hands of patients before they reach the pharmacy counter. Today, existing technology could make this process as easy as finding options for renting a movie across streaming services.

Specialty drugs break the model

Medication affordability has long been a concern that impacts both health and healthcare costs. Now, new trends intensify the need for greater transparency. For one, specialty drugs are being introduced to the market at an astounding rate.

These drugs are materially increasing healthcare costs, more so than utilization. In fact, the rate of hospital admissions and surgeries is actually declining. The drugs that are dominating specialty drug cost growth include medications and treatments for diabetes and immunology.

In this environment, we’re likely to see employers crack down on who gets GLP-1s and for how long. We’ll also see fast-tracked development of biosimilars for serious and chronic diseases, all in an effort to control medication costs.

Lack of information around medication pricing options can mean the difference between paying for a needed prescription and taking it as directed, or finding ways to reduce the expense on your own. Just like when I left the ED, that might mean skipping doses, adjusting them or forgoing the medication altogether. In fact, one out of three adults have made cost-savings decisions like these in the past year. Those numbers rise among women and low-income people, a recent poll shows.

Medication non-adherence, which is largely cost-related, contributes to billions in avoidable healthcare expenses each year. That’s because the decisions patients make when they can’t afford to purchase needed medications or take them as directed end up worsening patient outcomes, increasing hospitalization and prolonging illness.

As a result, in 2026, we will see an intense push for an “affordability fix” for drugs with no generic equivalent. There will also be demands for increased transparency around four categories of prescription drug prices that consumers pay: 

• The copay price set by insurance, which sometimes is higher than the cash-pay cost of the drug itself
• The copay coupon price when a manufacturer coupon is used alongside commercial insurance
• The cash price available to consumers without insurance and those who agree not to use insurance to purchase their prescription
• The direct-to-consumer price that consumers pay to drug manufacturers

Embedding affordability into care

At a time when 98 million prescriptions for patients starting new therapy are abandoned due to cost surprises, it’s critical all four categories of prescription drug prices are available so consumers can determine how to obtain needed medications at the lowest cost.

Moreover, when this information is integrated into existing healthcare workflow systems used by doctors and pharmacists, they will become empowered to help consumers overcome medication affordability challenges. They will also gain first line of sight into new options for medication affordability, like copay coupons, which in some instances cover 85% of the cost of the drug.

Take SKYRIZI, a biologic therapy that can help bring symptoms of Crohn’s disease under control. The price tag for the drug runs at just over $22,000 for a three-month treatment before insurance is factored in. If a patient were to pay a 20% insurance copay, they could be facing a cost of $4,400 out-of-pocket for each three-month treatment. On the other hand, a copay coupon (or savings card as it’s called here) from the drug manufacturer could bring this out-of-pocket cost down to just $0 per dose after commercial insurance is applied.

It could be a game-changer for medication affordability, but unfortunately, too few patients and providers are aware of options such as this. That’s a missed opportunity to put medication expense relief into the hands of those who need it most.

Ending the pharmacy counter guessing game

Until we give consumers complete visibility into their healthcare costs and options, we will struggle as a country to deliver on the goals of affordable, accessible care. 

By integrating medication price information — including pharmacy copay coupons — into existing patient, provider, pharmacy and payer workflows, we can eliminate the fear that comes with a trip to the pharmacy. This approach ultimately will empower consumers with the information needed to make informed choices for their health. The impact will be improved medication access and better health outcomes for all.

Source: weiyi zhu, Getty Images

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