Exploring the Lack of Transparency in Prescription Drug Costs: Contributors and Avenues for Reform.

The USA spent $722.5 billion on prescription drugs in 2023. The USA retail prescription drug payment and delivery system is notoriously opaque, which has historically made it nearly impossible for prescribing clinicians and their patients to predict the out-of-pocket cost of a particular drug at the pharmacy. This system involves drug manufacturers (i.e., pharmaceutical companies), insurers, pharmacy benefit managers (PBMs), prescribers (i.e., physicians and advanced practice providers), and consumers (i.e., patients). In this article, we provide a brief overview of the roles of and transactions among each of these entities. We focus in particular on areas where financial transparency is lacking. We then describe several targets for policy reform that gained momentum in the first Trump Administration, the Biden Administration, and the 118th Congress. These targets include increased transparency of pharmacy benefit managers' interactions, improved implementation of clinician-facing out-of-pocket cost estimators such as real-time benefit tools, and disclosure of drug prices to patients via direct-to-consumer pharmacies and direct-to-consumer advertising. Clinicians and their professional societies should use their powerful voices to advocate for increased transparency of a prescription drug system that costs the USA hundreds of billions of dollars each year.