A Simple FAQ for Employers
Several drug manufacturers now offer certain medications directly to patients at published cash prices. These programs are often online and promoted as simpler and more transparent. Because of that visibility, employers and brokers are getting questions about whether these programs are better, or whether they change how a pharmacy benefit should be structured.
Here’s what you need to know.
What is Direct-to-Consumer (DTC) prescription pricing?
DTC pricing allows a patient to purchase certain medications directly from a manufacturer-sponsored platform (or its pharmacy partner) at a set cash price.
In most cases:
- No insurance claim is submitted
- The prescription does not run through the PBM
- The patient pays out of pocket
These programs typically apply to specific medications — not an entire drug list.
Who can use these programs?
Generally, anyone with a valid prescription who chooses to pay cash. This is not an employer-sponsored benefit. It’s an option a member can independently choose.
Does it work with our pharmacy benefit?
Usually, no. If a member uses a DTC program:
- The claim typically does not process through the PBM
- It generally does not count toward deductibles or out-of-pocket maximums
- It may not appear in plan reporting
Because it occurs outside the benefit, visibility at the plan level may be limited.
Is the pricing really lower?
In some cases, yes. For certain high-profile medications, manufacturers have introduced self-pay pricing that is meaningfully lower than list price. Early examples include drugs like Repatha, Zepbound, and Ozempic, where advertised prices are 60% to 80% below list. However, these are direct-to-consumer (cash-pay) prices that operate outside of the pharmacy benefit, meaning they typically do not reduce employer plan costs or count toward member accumulators.
Are there oversight considerations?
Yes. When prescriptions are filled outside the PBM:
- Medication history may be split across systems
- Reporting may be incomplete
- Oversight becomes less centralized if members use multiple channels
This doesn’t eliminate pharmacist or prescriber involvement, but it can reduce consolidated plan-level visibility.
Do we need to change our strategy?
For most employers, no immediate structural changes are required. Members can already choose to use these programs independently.
A practical approach is to:
- Stay informed as DTC offerings expand
- Evaluate total cost impact, not just advertised prices
- Review PBM contract protections
- Consider reporting and oversight implications
Thoughtful evaluation is more important than reactive change.
Bottom Line
Direct-to-consumer prescription programs are expanding and may offer savings for certain individuals and specific medications.
They currently operate outside most employer pharmacy benefit structures. The appropriate response for employers is to understand how they work, monitor developments, and evaluate impact carefully, not to assume they replace traditional pharmacy benefits.
