Direct-to-consumer (DTC) prescription drug programs, from cash-pay pharmacy platforms like TrumpRx to manufacturer-direct distribution, are rapidly reshaping how patients access medications. While these models promise lower costs and greater convenience, their impact looks different depending on where one sits in the healthcare system.
Below, experts from VS Health Group examine the trend from three perspectives: the patient, the payer and PBM, and the biopharma manufacturer.
The Patient Perspective
By Glenn Voorhees, Vice President, VS Health Group
The burgeoning direct-to-consumer and cash-pay channel for prescription drugs is a mixed bag for patients. Delivered to our collective doorsteps with words like options, choice, and lower cost, it comes pre-sold as unambiguous progress for patients. But who does it help, and where does it break down?
Three patient archetypes appear to be the market for DTC and TrumpRx options: the uninsured, patients with subpar plans, and those with disposable income who want to avoid the hassle of navigating the barriers their insurance erects.
Patient #1: Uninsured
For the uninsured, a DTC and cash-pay channel could be meaningful for needed, lower cost drugs with an out-of-pocket cost that is equal to or lower than what a copay would be with insurance. It would provide access to a portion of needed healthcare, despite scarce financial resources. The worry is that, in some cases, the cash-pay cost is higher, and the patient would be better off using their resources to seek insurance and get better healthcare overall, not just that one prescription.
Patient #2: Subpar Insurance
For those with subpar plans, such as high pharmacy deductibles or formularies that block or have high cost shares for their prescribed medicines, the DTC and cash-pay channel also provides access, but at a higher cost than it should be. This prevents them from making progress toward their deductible or out-of-pocket maximums.
Patient #3: Privileged
For patients with disposable income, these options can free them from the hassle of calling their insurance and physicians to sort it all out. For an extra 25 bucks, they can get their prescription and go on with their day.
For all patients, a potential risk of cash-pay programs is that they will result in more fragmented care. With insurance plans removed from the loop, there could be less oversight into which therapies patients are taking and fewer alerts about drug interactions.
Bottom line: The DTC and cash-pay channel offers an illusion of choice and flexibility, yet it risks creating fragmented care and new affordability gaps for patients.
The Payer & PBM Perspective
By Anne Jacques and Jason Dohm, Partners, VS Health Group
The rise of direct-to-consumer distribution is also reshaping how biopharma manufacturers think about pricing, access, and supply chains.
While patients may see convenience and new access points, direct-to-consumer programs raise different considerations for health plans and pharmacy benefit managers.
In recent years, U.S. patients have evolved from passive participants in the healthcare system into informed consumers actively seeking creative ways to reduce their out-of-pocket prescription expenses. Initially developed for the uninsured or underinsured, direct-to-consumer distribution programs, such as GoodRx, InsideRx, TrumpRx, and manufacturer-direct platforms, have become an important and fast-growing component of healthcare. Many offer prices that aggressively compete with or are more attractive than prices paid by insured patients under their prescription drug benefit.
DTC programs come in many shapes and sizes and are often framed as a faster and more affordable path to medications. For insured patients, these models raise important questions from payers and pharmacy benefit managers about benefit design, care coordination, and long-term system sustainability.
Bypassing the Plan Benefit
When insured patients use programs like GoodRx or TrumpRx, prescriptions bypass their primary insurance plan benefits and may not count toward their plan deductible or out-of-pocket maximum. This might change, as an Express Scripts FTC ruling from February 4, 2026, stated such plans must provide covered access to TrumpRx as part of their standard offering upon relevant legal and regulatory changes. Prescriptions from DTC programs are also not eligible for manufacturer rebates.
Since insurers often serve as the central aggregator of prescribing information, health plans and PBMs may lack full visibility into all of a patient’s prescriptions. Missing claims history can affect multiple downstream programs, including SMART-PA, step therapy, concurrent drug utilization review, retrospective DUR, adherence, and closing gaps in care.
Many payers can now apply lesser of logic to ensure the lowest available out-of-pocket cost for patients. For example, if a GoodRx therapy costs less than the health plan’s price, the patient will pay the GoodRx price for that medication. However, this only applies to pricing, and it remains possible that PBMs will not see patient claims adjudicated and filled directly via GoodRx or TrumpRx.
Pros & Cons of Lower Cost Drugs
Payers and PBMs are not opposed to lowering drug costs for patients, particularly where their benefit plans may have gaps. For example, payers have struggled to justify coverage of costly therapies such as GLP-1 weight-loss medications, since doing so requires spreading the costs across all insured members, including those who do not use them. DTC models like TrumpRx may offer a path to access without all insured patients bearing the cost.
Notably, many medications available through programs like TrumpRx are brand-name versions of products that already have reduced cost, chemically equivalent, or therapeutically equivalent generic alternatives. There is a risk of brand preference over generics that could impact the market.
Bottom line: Payers and PBMs are keeping a close eye on rapidly evolving DTC models, which carry benefits and risks across the ever-changing healthcare landscape.
The Biopharma Manufacturer Perspective
By Amanda Schmutzler, Partner, VS Health Group
Today’s biopharma manufacturers recognize that traditional supply chains contribute to the high cost of therapies in the United States. So it makes sense that they see potential in direct-to-consumer models to improve patient access, transparency, and affordability of critical medicines.
Reducing Friction, Managing Risk
Ready to bypass pharmacy benefit managers, these companies are investing in digital infrastructure that can streamline distribution, accelerate time to therapy, and offer transparent cash-pay pricing options outside traditional insurance channels. Such shifts reflect a commitment to reducing friction in accessing therapies.
Manufacturers know that responsible implementation of direct-to-patient distribution matters. To protect patients, they must maintain high standards of clinical information, communicate about risks, and integrate with provider-led care to support safe, evidence-based treatment decisions.
MFN Pricing, PBM Transparency
Many biopharmaceutical companies are engaging constructively in efforts designed to lower drug prices and broaden access, such as the TrumpRx initiative. By participating in platforms with most-favored-nation pricing and direct-to-patient distribution, manufacturers can help reduce the out-of-pocket burden on uninsured or underinsured patients. Yet, there is concern that MFN pricing will create a revenue gap that could harm biopharma innovation in the United States.
Many pharmaceutical companies are eager to see PBMs have less control over pricing negotiations and more transparency in how drug prices are set. They believe the current rebate system can inflate list prices and make the market less clear. If PBMs move toward models that reward clinical outcomes instead of rebates, manufacturers see an opportunity to explore payment models that better reflect the real value of their medicines.
Bottom line: Biopharma manufacturers have a lot to gain and little to lose when it comes to implementing direct-to-consumer, cash-pay programs for their therapies.