Same Condition, Different Costs: Should Patients Pay Different Amounts?

Same Condition, Different Costs: Should Patients Pay Different Amounts?

Patients who have the same condition sometimes pay different out-of-pocket costs for their medications, but when is this differential more appropriate? Join the National Pharmaceutical Council (NPC) in tackling this dilemma in the webinar “Same Condition, Different Costs: Should Patients Pay Different Amounts?” on Tuesday, July 18, from 12 p.m.-1 p.m. Eastern Time.

It’s common for payers to shift some of the cost of treatments to patients using mechanisms such as tiered formularies and cost-sharing (e.g., copays and coinsurance) in an effort to better manage costs and encourage more efficient use of health care resources. However, it’s also important to recognize that cost-sharing structures are based on the cost of the medication or service, not on the appropriateness of the treatment or its value to the consumer or patient.

Although cost-sharing is a long-standing feature in benefit design, it comes with the potential for both intended and unintended impacts on adherence, costs and health outcomes. Patients with the same or similar condition may need different treatment options due to their genetic characteristic, comorbidities, socioeconomic factors or disease severity; therefore, patients may be prescribed medications on different formulary tiers and varying out-of-pocket expenses. For example, one patient may have a successful response to a lower-cost treatment, while another may require a more expensive drug regimen with higher out-of-pocket costs for the same condition.

So, when does a variation in cost-sharing make sense, and when it is less acceptable for patients with the same or similar conditions to have different out-of-pocket costs? What are the tradeoffs? What are the implications for health plans and employers who are designing and buying benefits? This webinar will address those questions as well as identify some of the ethical, legal and economic issues with copays based upon tiers versus medical appropriateness based on NPC research. Register now to participate in this insightful and candid discussion.


  • Jennifer Graff, PharmD (Moderator): Vice President, Comparative Effectiveness Research; National Pharmaceutical Council
  • A. Mark Fendrick, MD: Professor, Departments of Internal Medicine & Health Management & Policy, Director, Center for Value-Based Insurance Design, University of Michigan
  • Cheryl Larson: Vice President, Midwest Business Group on Health
  • Helen Sherman, PharmD: Vice President, Solid Benefit Guidance

Read NPC's related materials, including a study on variable cost-sharing published in the Journal of Managed Care & Specialty Pharmacy and an infographic detailing the study's main findings, to learn more.