Exclusive: GOP pushes sweetener for cash-pay drugs
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Republicans in Congress are trying to attract more people to direct-to-consumer drug purchases on platforms like TrumpRx by requiring insurers to count that spending toward patients' deductibles and out-of-pocket limits.
Why it matters: Paying cash for drugs has limited appeal for insured patients, in part because it doesn't help them get to the point where insurance picks up a bigger portion of their health costs.
Driving the news: Rep. Greg Murphy (R-N.C.) is unveiling a plan Tuesday that would require commercial insurers to apply prescription drug purchases from cash-pay platforms toward deductibles and out-of-pocket maximums, he told Axios first.
- Murphy, a practicing surgeon, said he recently took care of a patient who was paying $1,500 a month for a medication that was available on a cash-pay site for $15.
- "He should be able to take that $15 and say, I paid out of my pocket for this medication, and I am insured by this insurance company. It should go toward my deductible," said Murphy, who co-chairs the GOP Doctors Caucus.
Zoom in: The legislation would allow patients to take advantage of situations where a drug's cash price is lower than the cost through their health insurance.
- Drugs would have to be on a health plan's formulary to count toward a deductible. The bill doesn't apply to Medicare or Medicaid plans. It would work for platforms like Mark Cuban's CostPlusDrugs.
- Murphy said he's solicited feedback from the White House on the legislation.
Between the lines: The change could be especially valuable to the growing number of Americans with high-deductible health plans.
Zoom out: The Trump administration has been taking actions to move toward such a policy, too.
- Express Scripts, one of the country's largest pharmacy benefit managers, reached a settlement with the Federal Trade Commission earlier this year that requires it to count TrumpRx purchases toward deductibles and out-of-pocket maximums by the start of 2027.
- But the publicly disclosed terms are vague and raise questions like how an insurer or benefit manager would know an enrollee used TrumpRx, said John Barlament, an employee benefits lawyer at the law firm Reinhart.
Reality check: Requiring cash-pay drugs to count toward a deductible could lead plans to raise their premiums, said Benjamin Rome, a Harvard drug pricing researcher and assistant professor of medicine.
- "If you're going to put additional requirements on insurers on how they're going to set their benefit design, that does have consequences," he said. "It might be totally reasonable to do that — it just is not free."
Where it stands: CVS Health CEO David Joyner told a congressional hearing earlier this year that his company would let TrumpRx and CostPlus drugs count toward deductibles "if it lowers costs for Americans."
- But "for most people, the lowest drug prices are accessed through their insurance coverage," Tina Stow, a spokesperson for the insurer trade group AHIP, told Axios in a statement.
- "While brand drugmakers continue raising prices, health plans continue working to shield Americans from the full impact of those high and rising costs," she said.
What we're watching: Bipartisan frustration with health care conglomerates has been growing, and affordability is a key midterm election issue.
- Murphy is betting his bill could be folded into a broader legislative package aimed at lowering drug costs.
- He's also planning to introduce another bill that would apply only to drugs purchased on TrumpRx.
- "We're going to ... basically run the gamut to see which one has the greatest chance of being passed," he said.
