Novartis will launch a US direct-to-patient platform on November 1, 2025, offering select units of Cosentyx at a 55% discount to cash-paying patients prescribed the medicine. The company frames the move as a proof-of-concept for direct selling of specialty therapies, with plans to extend the option to other appropriate products and to pilot a direct-to-employer model that would sell Cosentyx—and potentially additional medicines—directly to large employers seeking lower, more predictable costs.
This is a direct challenge to the rebate-driven specialty channel. By approximating the net price that payers and pharmacy benefit managers typically capture, Novartis is testing whether manufacturers can pass through discounts to patients without going through the traditional rebate stack. If it works, the model could compress the gross-to-net gap, reduce abandonment tied to high out-of-pocket costs, and weaken the leverage of intermediaries that have dominated specialty drug economics. The strategic question is how far a manufacturer can scale a parallel cash lane without tripping regulatory wires or provoking aggressive payer countermeasures.
The timing is no accident. Cosentyx, a top-selling IL-17A inhibitor across psoriasis, psoriatic arthritis, axial spondyloarthritis, and hidradenitis suppurativa, now operates in a crowded, price-sensitive market with IL-17 and IL-23 competitors jostling for share. At the same time, employer frustration with opaque rebate flows, intensifying PBM scrutiny by regulators, and the rise of transparent cash options in generics and select brands have set the stage for specialty to follow suit. Novartis is signaling it would rather convert demand at a predictable, net-like price than lose patients to step edits, denials, and sticker shock.
For patients and prescribers, the appeal is straightforward: a faster path to therapy when coverage is denied or delayed, with out-of-pocket costs aligned to what the system already pays. Medical Affairs teams will need to translate eligibility rules, navigate interactions with existing support programs, and ensure safety monitoring and adherence support remain intact when patients obtain medicines outside plan-managed channels. Real-world evidence generation around persistence, disease control, and healthcare utilization in this cash-pay cohort will be critical to validate the model with clinicians and, ultimately, with skeptical payers.
For payers and PBMs, the move tests the limits of formulary control. Expect tighter utilization management, potential exclusion tactics, and pressure on specialty pharmacies whose economics depend on rebate and service fee flows. The mechanics matter: unit caps, pricing constructs, and pharmacy partners will be designed to avoid inadvertently resetting Medicaid Best Price or creating unintended 340B effects. But if employers embrace direct contracts that sit alongside or outside the pharmacy benefit, rebate walls and accumulator strategies become harder to maintain, and transparent net pricing gains political and commercial momentum.
Competitors in immunology now face a choice: match with their own direct options, anchor deeper employer partnerships, or double down on traditional access incentives. The broader trend line is clear. Manufacturers are moving closer to the point of care and point of payment, and specialty brands with mature evidence and broad labels are the first to test new rails.
The next signal to watch is scale. Do prescribers actively route patients to a manufacturer-run cash channel, do employers adopt carve-out contracts at meaningful volume, and do regulators clarify how these discounts interact with Best Price and plan design? The answers will determine whether this becomes a niche affordability valve or a structural reset of specialty drug distribution and pricing.
Jon Napitupulu is Director of Media Relations at The Clinical Trial Vanguard. Jon, a computer data scientist, focuses on the latest clinical trial industry news and trends.
