Wednesday, September 01, 2021

Coupons, PBM's ... oh my!

Over the past few years, my coverage of coupon-generating websites/apps has increased by a lot in this blog because those have emerged as a critical way for patients to get prescriptions at lower, PBM-negotiated prices even if they have yet to satisfy an annual insurance deductible or they have no insurance at all. 

In general, coupon-generating websites/apps offer consumers access to the deeper pharmacy benefits manager ("PBM")-negotiated prices on prescription drugs, at prices which are often substantially less than the prices you could otherwise attain as a consumer without the benefit of a commercial healthcare insurance prescription drug benefit which is also managed by a PBM. 

Is it stupid? Sure, but in the dog-eat-dog world of prescription drug prices, you as a patient are obliged to use their stupidity and greed against them!

In effect, coupon-generating websites/apps enable patient consumers to bypass their own PBM and use another PBM instead. It's odd that insured people might possibly find it cheaper to bypass a PBM hired by (or owned by) their own insurance company to manage pharmacy benefits and instead use a coupon to access a different PBM, but thanks to high-deductible insurance plans, a lot of people don't enjoy the benefit of PBM pharmacy benefits until they've satisfied a deductible, so using coupon websites/apps enables them to buy prescription drugs and the savings can be significant (especially on heavily-rebated prescription drugs like insulin). 

While the use of coupons means patients are essentially paying entirely out-of-pocket and contribute nothing towards any deductibles they must satisfy, the savings are often so substantial that only a fool pays what insurance says they should be paying as the bloated cash price for the same prescription drug. As noted, with heavily-rebated drugs such as insulin, instant savings of 75% off the bogus list price (or more) is entirely possible. If you use insurance, you end up paying over $200 for a single vial of insulin, while your insurance only credits you about $55 towards your deductible even though you paid a stunning $200 (or more) for that vial. There are so many entities involved in screwing patients in that scenario that it's kind of hard to know where to begin.

However, it's critical to acknowledge that commercial healthcare insurance companies are the real culprits (or enemies) behind runaway pharmacy drug prices (including insulin) in the U.S. today. There are a variety of reasons, and it wasn't always that way. But changes in healthcare insurance benefit designs created by healthcare insurance companies, and specifically the advent of high-deductible insurance plans (which now cover more than half of all Americans with healthcare insurance according to multiple sources, including The Commonwealth Fund) are the primary reason.

High-deductible insurance plans were initially created for employers who pay a policy's premiums as a way to supposedly share more healthcare costs with the covered individuals rather than via premium increases paid by employer "plan sponsors". In essence, until the covered individual satisfies an annual deductible amount, their healthcare insurance pays nothing. Nada. Zilch.

The IRS also has something to say about that. 

Recall that in 2018, I blogged (see my post HERE) about how insulin needed to be added to the list of "preventative treatments" covered by healthcare insurance companies pre-deductible. It really should have been the responsibility of insulin manufacturers such as Lilly, Novo Nordisk and Sanofi to get their insulin products added to that list. Those companies hire expensive Washington DC lobbyists who could have been deployed to that task and gotten insulin added to the "preventative treatment" list, but the companies never bothered

We should be asking ourselves why didn't they do that?

The Trump Administration had a very long list of failures when it came to reducing prescription drug prices for Americans, but one accomplishment which occurred while the former reality show host was in office happened with some assistance from Congress. Through Congressional testimony on the subject of runaway insulin prices, it had already become very clear that diabetes treatments needed to be added to the very limited IRS list of "preventative treatments" which were eligible for pre-deductible insurance coverage. Congress finally saw their own failure to add insulin to the IRS list, hence lawmakers in Congress finally helped to make that a reality in 2018. Regardless of how it happened, the bad seeds in the insurance industry delayed implementation for many, citing that they could not implement the change until various insurance plan years were signed or renewed (that was a falsehood, they just did not WANT to do so because they wanted to keep lining their pockets with more Rx rebate dollars paid on insulin for at least another year or two).

But time has passed, and increasingly, more and more Americans will now enjoy the benefit of pre-deductible insurance coverage of their insulin. That was long-overdue. I fault the drug companies (Lilly, Novo Nordisk and Sanofi) for their failure to get insulin on the IRS list of "preventative treatments" in the first place. Those companies never used their expensive lobbyists to do that, but they easily could have and should have done so while their lobbyists fought all Congressional and state efforts to control prices. The insulin pricing crisis occurred because Lilly, Novo Nordisk and Sanofi were lazy and they allowed it to happen while naïvely thinking they could safely blame the other party. It didn't quite work out that way, but if the companies were actually paying attention, they really should have known better.

However, for those without the benefit of insurance coverage (including many still satisfying high-deductibles) of insulin and other diabetes supplies, two of the largest insulin makers (Sanofi being the notable exception) implemented an important affordability option as a means of bypassing the Rx rebate mess they alone had created and continue to perpetuate. Their so-called "authorized generic" versions of these insulin varieties have unique FDA NDC numbers, but they are really just Humalog and Novolog with different "generic" labels on them. 

As noted, the "authorized generic" versions of the insulin products have unique NDC numbers. The NDC, or National Drug Code, is a unique 10-digit or 11-digit, 3-segment number, and a universal product identifier for human drugs sold in the United States. The 3 segments of the NDC identify the labeler, the product, and the commercial package size. But Lilly Humalog and Lilly Insulin Lispro is the same exact medicine (made on the same assembly line), and the same is true for Novo Nordisk Novolog and Novo Nordisk Insulin Aspart even if they have different NDC numbers which attempt to bypass the Rx rebate problem.

Lilly was the first entity to introduce an "authorized generic" version of Humalog branded as Lilly Insulin Lispro which was to be available in U.S. pharmacies at a 50% lower list price. In reality, however, savvy consumers quickly discovered they could buy the "authorized generic" product for about 75% off the bogus list price by using freely-available coupons found at GoodRx and some rivals. Coupons are by definition, are a voucher entitling the holder to a discount for a particular product. But coupons have become a way of life in the messed up U.S. prescription drug business. Some would argue that only a chump pays full price. Manufacturers are giving discount coupons away to anyone and everyone, and now that includes patients because of PBM greed.

The result of Lilly's "half-price" Insulin Lispro introduction was that with a GoodRx coupon, Americans can now easily buy insulin sold at prices for about what people in Germany pay for the same insulin (even without insurance), which seems entirely rational. 

For example, with a GoodRx coupon, the price for a vial of Lilly Insulin Lispro is $56.68 at Walgreens. Elisabeth Rosenthal, who is editor in chief of Kaiser Health News wrote in an article published by the New York Times (see ) arguing that the "half-price" Lilly promised wasn't such a bargain, but thanks to coupons, the price is comparable to what Europeans pay for the same insulin, writing:

"In Germany, the list price of a vial of Humalog is about $55 — or $45 if you buy five at a time — and that includes some taxes and markup fees."

The key to that price is a readily-available coupon from GoodRx. Otherwise the price is a more costly $137.35 per vial, which is still quite overpriced.

Rival Novo Nordisk quickly followed suit when the company's Novo Nordisk Pharma Inc. unit introduced what the company called an "Unbranded Biologic" with the introduction of Novo Nordisk Insulin Aspart.  Of note was the fact that Sanofi never introduced "authorized generic" versions of any of its insulin products. Lawmakers took note that the company did not really have an answer when it was asked what affordability efforts Sanofi had taken at the time to address its runaway insulin prices. It's anyone's guess what Sanofi is doing since it is now in preparation of being spun-off as a company to become known as EuroAPI. 

Below are the company press releases for the introduction of "authorized generic" insulins:

Lilly to Introduce Lower-Priced Insulin, PR Newswire, March 4 2019,  

Novo Nordisk launching additional US insulin affordability offerings in January 2020, PR Newswire, September 6 2019,  

On September 28, 2021, Lilly announced that the company planned to reduce the list prices on its Lilly Insulin Lispro by an additional 40% effective January 1, 2022. See the press release at All told, the new price of Lilly Insulin Lispro will be (according to the company) 70% off the list price for brand-name Humalog. The reason is because in the year since introducing Lilly Insulin Lispro, it now accounts for one-third of all Humalog sales, bringing sales growth to the company (even while it loses out to Novo Nordisk which now pays 74% of its gross insulin sales as rebates paid to PBM's) in securing commercial healthcare insurance company formulary placement for brand-name Humalog, which Lilly thinks a lower out-of-pocket price for consumers can enable the sales to continue.

That said, while biosimilars have the potential to save money, so far, none on the market are any cheaper than the brand-name products. For example, while there are two approved biosimilar versions of the basal insulin analogue glargine, none are cheaper than Sanofi Lantus, which was the innovator of that insulin variety. Some of the problem is because Lilly's biosimilar of Lantus branded as Basaglar is only sold in the significantly more costly insulin pen delivery device vs. older vials. That means patients reliant on glargine are overpaying because only the most costly delivery method is sold for one of the approved biosimilars. No wonder hardly anyone buys Lilly's Lantus-copy known as Basaglar. Patients struggling with cost should probably NOT be using the most expensive delivery method: insulin pens. Meanwhile, Viatris/Biocon Semglee is sold as both vials and pens, but they are slightly more expensive than brand-name Lantus sells for with a coupon from Sanofi. That's what's known as a "rebate wall".

Coupons are really just a way to deliver PBM-negotiated prescription drug discounts to people, including those without healthcare insurance or those trying to satisfy an insurance deductible. Part of the problem is the pharmacies are obliged under their PBM contracts to have artificially-high cash prices which they call their Usual & Customary (U&C) prices. That means the PBM's (which are now owned by the likes of United Healthcare-OptumRx, Cigna-Express Scripts and Aetna-CVS Health/Caremark) are the ones telling pharmacists they cannot offer better prices if someone pays cash. On that, we can blame byzantine PBM rules, and their commercial healthcare insurance company owners indirectly because the PBM's are really tying the hands of pharmacies from offering better prices to cash-paying customers.

Still, coupons are now routinely generating massive prescription drug discounts, often 75% to 95% off the bogus cash prescription price. On insulin, prices are instantly about 75% off depending on which pharmacy you buy it at. In general, coupon-generating prescription drug websites/apps work in the following way:

  1. Start with the pharmacy's bogus U&C cash prescription price
  2. Save money for consumers by providing the with easy access to a PBM's discounted network rates on prescription drugs typically sold as service to commercial healthcare insurance companies
  3. Collect a portion of the transaction fee that pharmacies ordinarily pay to a PBM for paying a drug claim

Behind-the-scenes with many coupon-generating websites/apps are the PBM's that prohibit your pharmacist from giving you a better price as a cash-paying customer. 

The biggest PBM's are now wholly-owned by the largest commercial healthcare insurance companies. PBM's are a deeply corrupt business. These entities are self-serving at the expense of independent pharmacists, drug companies and patients alike, and PBM's are so used to lying they can no longer discern genuine fact from their own fiction created by their PR departments. Entire books and countless articles have been written about PBM wrong-doings, and lawmakers badly need to fix the PBM's if they ever wish to bring U.S. drug prices back down to earth. Lawmakers are finally starting to realize the PBM's are the bad seed in a very dysfunctional market.

The FTC has a role to play too. So far, the FTC has failed.

Recall that a series of mergers in the 1990's actually put drug manufacturers including Merck, Eli Lilly & Company, and SmithKline Beecham in direct control of the most powerful PBM's at the time. That ownership enabled drug companies to then view their competitors' pricing information and place their own drugs over their rivals' on PBM formularies. As the American Prospect chronicled (see

"That raised eyebrows," said attorney Linda Cahn "It's such a conflict-of-interest. Obviously, the PBM's were unlikely to negotiate aggressive terms with their manufacturer parent companies."

In 1997, Linda Cahn filed class-action lawsuits against the two largest PBM's in America (at the time), Medco (then owned by Merck) and PCS Health Systems (then owned by Eli Lilly), for breaching their fiduciary duty to employee health plans and increasing drug costs. The high-profile cases finally motivated the Federal Trade Commission (FTC) to finally crack down on the PBM/drug company alliance. After a series of settlements that removed the benefits of the vertical integration with the drug companies by requiring decisions on drug formularies to be delegated to an independent third-party, Lilly, SmithKline, and Merck all sold their PBM's.

But although the antitrust laws initially worked, PBM's kept consolidating, insisting that gaining market share would produce benefits for consumers. And this time, the FTC kept their hands off. SmithKline sold their PBM, Diversified Pharmaceutical Services, which later sold to Express Scripts in 1999 (now wholly owned by Cigna). PCS was bought by Advance Paradigm in 2000, and the new company then became part of Caremark in 2003. And then, Caremark itself found a buyer in 2007 - CVS, one of the nation's largest pharmacy chains. The Bush-era FTC barely blinked an eye at this vertical combination of PBM and pharmacy and never recommended any divestitures or business changes.

"That was the first unholy union," says consultant Susan Hayes Caremark steered its giant patient network toward CVS stores, through lower co-pays or out-of-network bans. They also got to see all the information in CVS's other PBM deals, using the data to underprice rivals.

There was a time after the drug companies divested themselves of PBM's when they were large independent businesses. It did not last.

Relentless PBM industry consolidation meant that by the 2000's, suddenly there was vertical integration with the healthcare insurance companies that once hired them (insurance now owns the biggest PBM's) which has resulted in formerly big PBM's like Express Scripts now being a wholly-owned business unit of Cigna. Ironically, the Cigna acquisition of Express Scripts was approved without question by the U.S. Federal Trade Commission which is supposed to prevent unregulated monopolies from existing. The FTC also readily approved CVS Health's (owner of the largest PBM known as Caremark) acquisition of the commercial healthcare insurance company Aetna within weeks of giving the Cigna-Express Scripts acquisition a thumbs-up.

The reality is that much like the drug company ownership of PBM's, insurance company ownership is also a deeply anti-competitive threat which truly requires FTC un-doing. How soon that occurs remains to be seen, but we now know it is on FTC's radar screens. Their perspective was from the perspective of community pharmacies. To be sure, those entities have indeed been directly harmed by PBM practices, but the harm is far more widespread than that, and yet PBM's remain incredibly arrogant organizations. 

As the Stigler Center for the Study of the Economy and the State at the University of Chicago Booth School of Business publication known as ProMarket chronicled, the FTC stands out as a government entity which has repeatedly failed to protect Americans from monopolization of prescription drug pricing in the U.S. in spite of clear signs of anti-competitive behavior among PBM's. See their article at for more.

Only now, the latest vertical integration is with insurance companies, which I think FTC is finally rethinking now. How quickly FTC gets its shit together on PBM's remains to be seen. 

FTC chair Lina Kahn is slightly more interested on monopolization in the tech space, including advertising with Google, web services/hosting with Amazon, and Facebook in social media. However, the calls for her to look into PBM's are getting louder and more frequent. Of note is that an early July 2021 public FTC meeting featured testimony from independent pharmacies being harmed by PBM contracts, so its definitely on FTC's radar screens. It is simply too big to ignore.

David Balto, an antitrust litigator and former official with the Federal Trade Commission says: "It's OK to have intermediaries. But PBM's make a fabulous amount of money, even though they're not buying the drug, not producing the drug, not putting themselves at risk."'

Back to PBM-powered coupon-generating websites/apps like GoodRx. The first lesson for consumers who wish to use Rx coupons is to compare ALL of them, and verify the price that your pharmacy will charge you for a given prescription. Use whichever coupon website/app offers you the deepest discount. You are making a choice based upon what saves you the most money since you are paying out-of-pocket.

Behind the scenes of most (not all) Rx coupon-generating websites/apps are a PBM (or in some cases, several PBM's). Looking at the PBM space, of them, only MedImpact Healthcare Systems, Inc. is a San Diego, CA based PBM that remains independent. MedImpact is the last (meaning it is currently the ONLY) independent, stand-alone PBM (although, in truth, the company is de facto controlled by its single largest customer, Kaiser Permanente). The others have all been acquired by the big commercial healthcare insurance companies (or in a slight reversal of roles, in the case of Aetna, which was acquired by CVS Health, as CVS Health is also the operator of the largest PBM known as Caremark, which reportedly pays for about 30% of the nation's prescription drug purchases).

Due to MedImpact's "last man standing" status as an independent PBM, the company was among the earliest to spot sales opportunities with prescription drug coupon websites/apps. MedImpact works with virtually all of them. To my knowledge, as of 2021, MedImpact is a PBM which helps to power many of the coupon-generating websites/apps. Which explains why the discounts with different coupon-generating websites/app are often about the same with many of them for the same drugs.

Anyway, back to Rx coupons. They are curiously enabled by PBM greed and willingness to partner with virtually any revenue stream willing to do business with them. The PBM's are literally proverbial whores — they'll do it with anyone, for a price. 

Side note: While Amazon has been cited as a threat to GoodRx's coupon business, the reality is that GoodRx works with Amazon, but is not truly a competitor. In GoodRx's most recent investor call, GoodRx co-founder and co-CEO Trevor Bezdek said:

"Companies have tried to copy our model or try different models, but none have been able to impact our business. Amazon has been trying to grow pharmacy delivery business. We believe they have not been successful. Mail-order prescriptions only make up about 5% of fill count in the U.S. even through COVID, mails remained a small piece of overall volume and is now starting to decrease as COVID eases."

Unlike insurance companies, consumer-facing tech companies such as GoodRx and others like it are a beneficial outcome (thankfully). But the underlying PBM's are still enabling it. But the FTC has a LOT to look into when it comes to PBM's. But I think it is likely to come soon.

Which PBM's "Power" Particular Coupon-Generating Websites/Apps?

SingleCare is currently unique among coupon-generating websites/apps in that it contracts directly with pharmacy chains to negotiate discounted cash prices rather than using a PBM or combo of PBM's. It is managed by Boston-based RxSense. But its unique business model is a win-win model for pharmacy chains and, to a slightly lesser extent, consumers, although the discounts given to the consumer may not be quite as deep as PBM-powered coupon generating websites/apps on some drugs. Still, on less-heavily rebated prescription drugs which have more room for price variability, including CGM sensors, SingleCare may end up offering the best discount coupons. 

For example, if you search on the SingleCare app for "Dexcom G6 Sensor (Guardian Sensor 3)", you will find some decent discount coupons there. Note that when you search using SingleCare app, it tends to default to Freestyle Libre sensors which aren't the same thing, but when you select the "Brand vs. Generic" option, the Dexcom sensor coupons are there. It does not appear to be an issue when using the web, but the key is to beware of what you are searching for and what the app actually delivers (sometimes they are not the same thing). Also, be certain to note the quantity. The default seems to be a quantity of 2, but I believe that means two boxes of three sensors in each box, so be certain to note the correct quantity of right brand of sensors the SingleCare coupon(s) actually apply towards. Its a quirk of using coupon-generating websites/apps to buy diabetes supplies.

BlinkHealth uses the PBM known as MedImpact. As noted, MedImpact is the ONLY stand-alone PBM. 

ScriptSave WellRx also describes itself as "a member of the MedImpact family of companies". 

Still another coupon-generating discount website/app is branded America's Pharmacy which is a discount program also powered by the PBM MedImpact. I have not really found that this one offers  prescription drug prices any lower than the three others, although this one does offer discounts on "authorized generic" insulin varieties which may be useful should another coupon option not be working. Prices are not necessarily any better than rivals, but this is still an option worth keeping in mind.

GoodRx is somewhat unique relative to the other coupon-generating websites/apps in that it uses MedImpact, but it also has non-exclusive contracts with Cigna's Express Scripts, United Healthcare's OptumRx, and Navitus (which is a PBM owned by the nonprofit hospital chain SSM Health & Costco). That unique non-exclusive PBM arrangement enables GoodRx to compare drug prices from different PBM's and choose the one that offers the lowest price. In April, GoodRx acquired a rival coupon website/app known as RxSaver by RetailMeNot from Vericast which is currently still operational but is unclear for how long, and GoodRx has since cut the price of Novo Nordisk's Insulin Aspart by 22% (previously, RxSaver had lower prices on Novo Nordisk Insulin Aspart).

A relative newcomer (as of 2017) to the coupon-generating website/app space is one operated by the drug wholesaler McKesson, which has a small, but relatively new discount card called ScriptHero (through CoverMyMeds, which McKesson acquired in 2017), which is actually powered by internally via CoverMyMeds, as well as the aforementioned website/app 1) SingleCare as well as the PBM-powered website/app 2) ScriptSave (MedImpact).

ScriptHero could potentially be attractive to independent/community pharmacies, given McKesson's relationship to these types of entities. For instance, if a community pharmacy is able to negotiate the PBM/discount card taking less spread, it could mean that the community pharmacy is neutral (if not superior) compared to a transaction being processed with GoodRx. However, McKesson itself promoting a program (i.e. ScriptHero) to individual consumers is less of a threat relative to McKesson working with the smaller community pharmacies, as the former would be just another discount card in the marketplace trying to attract consumers.

As for patient prices, ScriptHero is (like many of the others) hit-or-miss. But by combing several options, McKesson hopes to provide a more comprehensive Rx  coupon-generating website/app. Some generic drugs are priced well with this option, plus it also offers discounts on insulin which may not be the lowest prices available anywhere, but they are also not terrible, either. For patrons of small, community pharmacies, this may be a good way of continuing to patronize those businesses while also getting discounted prices on certain medicines. As with the others, the best option is to check them all and determine which one(s) offer the prices you are willing to pay. Note: CoverMyMeds reports that on June 3, 2024, ScriptHero will shut down and operations will cease.

PBM Operated Coupon-Generating Websites/Apps

To the best of my knowledge, most of the other coupon-generating websites/apps are operated by insurance company-owned PBM's. One suggestion is to use them if and when they can get you the cheapest price, otherwise ignore them.

OptumPerks was originally operated by the United Healthcare Group's PBM known as OptumRx, which also operates the Rx discount card. OptumPerks is basically a re-branded version of what was previously known as SearchRx (which the company acquired, SearchRx no longer exists as its own brand/app).  OptumPerks has not generally delivered the lowest prices for  medicines my family uses (so far), but that's because we already satisfied our deductible for 2021. However, looking forward to my plans for 2022, I did find Optum's prices for rosuvastatin calcium (generic Crestor) tablets to be lowest when one orders from Optum Mail Order Pharmacy. Admittedly, the price differential (less than $1 for a 90-day supply) was marginal compared to the prices attainable from our local supermarket pharmacy, but this was still better than many of the alternatives sellers for that particular drug. United Healthcare's Optum business sold OptumPerks to RVO Health, LLC and since that acquisition, I have found OptumPerks to be largely useless.

Like its rival at UHC's OptumRx, Cigna's Express Scripts PBM unit also operates a coupon-generating website/app called InsideRx While InsideRx had its origins as a program offered in combination of Express Scripts and GoodRx originally (see the 2017 press release HERE), Express Scripts later opted to develop its own coupon website/app. The program initially focused on a limited number of brand-name drugs, and has since evolved to offer a much wider number of drugs including generics. 

InsideRx's prices on generic drugs, in particular, appear to make this one worth considering, often with lower prices than several rivals. While Cigna-Express Scripts' InsideRx website/app doesn't allow users to sort by price, making it kind of cumbersome to use, plus there are different entries in its system for both branded and generic drugs, meaning you must conduct a search twice to discover the lowest price, it is still one to be aware of. 

It is perhaps no irony that the InsideRx website/app offered by Cigna's Express Scripts PBM unit quite often (sometimes quite drastically) offers the lowest prices on certain drugs if consumer buy uses the InsideRx coupons at Express Scripts Mail Order Pharmacy, especially on certain small molecule generic medications (such as pills) and occasionally on preferred formulary brands of blood glucose test strips (which is apparently Roche AccuChek right now). \


For example, my spouse had eye surgery and uses a steroid eye drop called Prednisolone Acetate 1% (brand name: Pred Forte). There, I found InsideRx and Express Scripts mail order pharmacy had the lowest price at $15.39 for a tiny bottle (5 ml in size) of eye drops. By comparison, competing pharmacies (using coupon-generating websites/apps) all had prices ranging from around $23/bottle to a stunning $173.74/bottle. Keep in mind that the size of these bottles is just 5 ml. I can't imagine paying nearly $174 for that! 

Something else we examined was the price of a hypertension medicine called eplerenone 50 mg tablets (which is a generic drug), yet our insurance was charging $48.40 even after satisfying the deductible for a 30 day supply which seemed very high for a generic pill. Initially, we used a coupon from InsideRx, which resulted in savings of $10.00, so the total was still $38.40 for 30 tablets which is no bargain for a generic drug. But at least that enabled us to buy it with the existing refills we already had at the pharmacy, only getting a discount. However, Express Scripts Mail Order pharmacy's price for the same generic drug was just $8.72 for a 30 day supply! 

When we ordered, we ordered a 90 day supply, so the cost was $25.39 (or about $0.28/pill vs. $1.61/pill when we bought it from CVS AFTER satisfying the deductible). Express Scripts was easily the least costly option we've found on that drug anywhere -- a savings of 82.5% which is insane! So even while our insurance company is contracted with CVS Caremark to offer pharmacy benefits, we still found it more advantageous financially to bypass them completely and buy the drug from Express Scripts cash mail order pharmacy, even though Express Scripts is not the PBM our insurance plan uses. Still, Express Scripts does say the price could change by the time of our next order, so we shall see if the savings continues (we may not refill it there if the savings isn't great). It's pretty nuts!

Cigna's InsideRx/Express Scripts Cash Mail Order Pharmacy replicates the savings on some other diabetes-related items. For example, there's a new rival to Gvoke Hypo Pens called Zegalogue, which is a glucagon analogue which does not require reconstitution. Although no one exactly rivals the $25 co-pay coupons on commercial healthcare insurance offered directly from Zealand Pharma, the company conveniently exempts those on Medicare, for example. However, if one is in need of reduced prices on that, the average retail price of that is $741.61, but InsideRx/Express Scripts sells it for just $300.74. Its still not exactly a bargain, but is nevertheless around half of what any other entities (including with GoodRx coupons) are charging for the same item.

Still, Express Scripts Cash Mail Order Pharmacy does say "At this time, Express Scripts is unable to accept mailed-in prescriptions" which means that in order fatten Express Scripts' own bottom line, the company currently only accepts e-scripts (not paper scripts) from your doctor. First-time orders are likely to sit in queue without a payment method on file. So it does say that consumers may call "For help with your prescriptions filled through the Express Scripts Pharmacy or your online account, you can call us at 1-844-604-9164. Our support team is available 8:00 AM - 9:00 PM ET." That could be a hassle for doctors offices that aren't equipped to handle escripts.

This does appear that since Express Scripts lost all of its major PBM clients and was forced to sell itself to Cigna at bargain-basement prices, perhaps a new direction for Express Scripts has become a direct-to-consumer model? Maybe. Given the apparent improprieties associated with generic drug pricing unveiled by the Connecticut Attorney General (whose cases were enjoined by the AG's for 50 other states/territories including Puerto Rico), anything is possible, but it appears Express Scripts might be helping consumers (and their pets!) navigate through some of that. Who knows.

For consumers, lowest price is usually the best place to buy most prescription drugs unless they need to receive it immediately at a pharmacy for an acute illness. Rivals United Healthcare Group's OptumRx card known as OptumPerks and Caremark (owned by CVS Health) seem to be less aggressively promoting the use of their own mail order pharmacies compared to Express Scripts.

On the coupon-generating websites/apps operated by the PBM's themselves, personally, I've generally been underwhelmed by the discounts offered via insurance company PBM-owned coupon websites/apps on everything except generic drugs; the discounts offered just have not been that great in my experience, and many drugs or medical devices are excluded completely.  Still, they are important, because you never know if they will offer the lowest price.

Another coupon-program is from CVS Health and Novo Nordisk which introduced a program they call Reduced Rx, a program that provides some insulin products at lower cash prices to uninsured patients. Reduced Rx is similar to Inside Rx in that both operate as a PBM-backed discount program that passes rebates directly to patients at the point of sale. Reduced Rx includes only three old-school Novolin products. Perhaps it was created to widespread public criticism of insulin prices specifically. Reduced Rx is a discount program on a very limited number of prescription insulin varieties, however, unlike other PBM coupon-generating websites/apps, it does not offer discounts on an entire PBM formulary. 

Author P.S., February 6, 2022: As I've blogged (see HERE) about PBM-powered prescription drug price comparison and coupon-generating websites/apps, a smaller PBM known as Welldyne, Inc. (and its subsidiary Welldyne LLC), like several of its larger PBM counterparts (including Express Scripts and OptumRx, as well as MedImpact) also owns/operates its own prescription drug price-comparison site and coupon-generating website/app branded as WellCardRx

Patients must register to activate their card membership (which is free) to use the WellCardRx app or coupons printed from its website at their participating pharmacy. The activation can be done at and answer a few questions such as name, address, etc. One field which must be answered is called "Referring Group ID", and individuals are required to enter a valid value in that field for the company to send you an active card. However, the site says the default value for "Referring Group ID" which is acceptable is: WDRXDEF. Another field which is not required to activate the card, but the field value must be provided to your pharmacist is the "Member ID" field. For that, individuals may use their 10-digit phone #, followed by a 2-digit person code, and those 2-digit codes include: 01=Member, 02=Spouse, 03=Dependent etc. Once you've registered, the website will produce a card with the relevant fields needed for use at your pharmacy, and/or on your smartphone app. However, as I always recommend people to do, invest some time before visiting your local drugstore to determine which coupon gives you the best price for each drug. To search WellCardRx for prices, visit and then go to the paragraph marked "Discount Pricing Tool" and then select the link there to see discount price estimates for prescription drugs in your area using WellCardRx. It does note: "Discounted prices are estimates. Savings will be calculated at time of drug purchase." That means verify the price with your pharmacist.

GoodRx: A Winner for Consumers

Of all of them, I have consistently found GoodRx to be the one app I return to over and over for prescription drug discounts when I don't enjoy coverage from insurance (pre-deductible). The reason is because it has coupons for virtually any prescription imaginable except for the newest, still patent-protected drugs. It has coupons for insulin of many varieties. In fact, it has even started to offer coupons directly from drug manufacturers if it has no discounts available, meaning it will refer patients to one of Sanofi's coupon pages enabling them to get coupons for Lantus, Apidra or Admelog or the company's highly-concentrated insulin varieties (such as Toujeo, which is U-300 insulin glargine [basically 3x as much insulin per unit]). GoodRx also has coupons for test strips (the discounts exist, but aren't necessarily enormous, but anything helps).

Beware of how I blogged about using generic strips made by different manufacturers that work in the old-school OneTouch Ultra meter, catch my post HERE), plus it some coupon websites/apps offer coupons on CGM's (as my previous blog post noted, right now Abbott's Freestyle Libre has the biggest coupons because the company is trying to establish itself against Dexcom, so its cutting sensor prices to do so). Some coupon-generating websites/apps have coupons on Dexcom sensors and transmitters, although some have discovered that the discounts seem to be better on SingleCare for Dexcom sensors. Recall that SingleCare contracts directly with major pharmacy chains to negotiate discounted cash prices, so it's a slightly different discount model. On SingleCare, a search under "Dexcom G6 Sensor (Guardian Sensor 3)" and coupons come up. Note the number of sensors is important to be aware of; apparently some pharmacies will sell you a single sensor as opposed to a box of three sensors). Also, CGM sensors tend not to be very heavily-rebated via PBM's (at least not presently), which means SingleCare is well-positioned to offer deeper discounts on those sold at pharmacy chains, whereas on drugs, the discounts may not be as generous.

As I hinted, I've generally been underwhelmed by insurance company PBM-owned coupon apps; the discounts aren't that great and many drugs or medical devices are omitted completely. As noted, InsideRx doesn't even allow the user to sort by price, making it more cumbersome to use, plus entries are different for brand-name and generic medicines. PBM coupon app discounts using PBM-operated coupon websites/apps on insulins do not exist, even while the PBM's are collecting manufacturer rebates of 74%.

The lesson for consumers is: Try searching each coupon-generating website/app, and search under both brand-name and generic drug names and at a pharmacy located near you. Prices can vary from pharmacy to pharmacy, but not always. 

Each website/app has different search functionality, some are good, some are not-so-good. But one never knows which might deliver the best prescription drug discounts. If you are bypassing insurance while satisfying deductibles, heavily-rebated drugs like insulin are best bought (if insurance doesn't cover it pre-deductible) with GoodRx coupons on authorized generic rapid acting insulin analogues. The discounts are roughly 75% off the bogus cash retail price. Coupons are not as good on basal insulins such as Lantus or Novo Nordisk's latest "Lantus killer" products. There, the Sanofi coupons which reduce the cost to $99/vial which seems to be the least costly option (at least until there are a host of different biosimilar knockoffs).

Currently the interchangeable Lantus biosimilar known as Semglee from Viatris/Biocon is actually more expensive (GoodRx reports the lowest list price as $105.47/vial) than brand-name Lantus is with manufacturer coupons (priced at $99.00/vial with a coupon from Sanofi), so beware biosimilar does not always mean less costly to patients. The same is true with Admelog, which is an insulin lispro biosimilar of Lilly Humalog/Insulin Lispro which is made by Sanofi (soon to be EuroAPI). There, you can pay either $99/vial for Admelog with a coupon from Sanofi, or $58.38/vial for Lilly Insulin Lispro with a GoodRx coupon. I vote for Lilly Insulin Lispro which costs about half of what the biosimilar costs. 

The following image was taken from Lilly's Q2 2021 earnings presentation made to investors. Note that while overall Humalog sales have essentially been flat (the chart on the right side), most of the recent sales growth has been due to the less costly authorized generic called Lilly Insulin Lispro. That was quite a stunning development which proves unequivocally how much prescription drug rebates paid to PBM's owned by commercial healthcare insurance companies have impacted the market. Regardless, consumers should use the tools available so they can navigate a dysfunctional pharmaceutical most market effectively.

Other items tend not to be discounted as much because those aren't rebated as heavily as insulin is, hence the discounts are generally not as great. But search all websites/apps and make your choices based on which costs you the least amount of cash out-of-pocket. Verify with your pharmacist what they will actually charge you for the products using a coupon; prices can and do change. The key instructions are to: #1) search each coupon-generating website/app using both the brand-name and generic drug names #2) verify both the potency (e.g. the number of mgs in each tablet) and the quantity you plan to buy and finally #3) you may also wish to verify the price offered by different pharmacies for the same drug. Some, such as GoodRx, enable you to sort the findings from lowest price to highest price, but others such as Cigna-Express Scripts' InsideRx do not offer that ability. Occasionally, that has won on lowest price for certain generic drugs when you use their mail order pharmacy, so you never know.

An informative YouTube video released by CNBC addresses the dysfunctional nature of the U.S. prescription drug market, and includes interviews with such experts as Adam Fein of the Drug Channels Institute as well as Doug Hirsch who is a co-founder of the prescription drug discount coupon generating website/app (powered by PBM's) known as GoodRx, and the obligatory "other side" comment from Greg Lopes from the PBM trade organization known as the Pharmaceutical Care Management Association (PCMA) who again, misrepresents the benefits his industry provides. The video can be seen below, or at


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