RICHMOND, Va. (WRIC) — A woman uses her insurance to purchase the drug Sprintec. Her copay was $50.
However, if she didn’t use her insurance and paid cash for the drug, it would only have cost her $11.65. That’s a difference of $38.35.
This is called a copay clawback. It’s a little-known secret driving up the price of your prescriptions.
Douglas Hoey, CEO of the National Community of Pharmacists Association explains to 8News how it works.
“The insurance company tells the pharmacy what to charge. The insurance company overcharges the consumer and then the insurance company takes the extra money back from the pharmacy that the pharmacy was forced to collect,” Hoey said.
It’s carried out through a middleman known know as a pharmacy benefit manager or PBM.
PBM’s negotiate drug prices with drug companies on behalf of your insurer.
Some PBM’s then charge a co-pay that exceeds the cash price.
Your pharmacist is expected to charge whatever price insurers set, and that middleman pockets or clawbacks the profit.
“The insurer sends back a message that says this is how much to charge the patient. That is the first time the pharmacy knows how much a patient is going to pay,” Hoey explained.
Many pharmacists can’t tell you that if you just paid with cash it would be cheaper. They’re sworn into secrecy with a sort of contract gag clause.
“The pharmacist is restricted or actually threatened by the PBM to tell the patient that they can maybe get the drug cheaper if they use cash,” Hoey said.
There is a language in the contract that implies if the pharmacist shares information with the consumer … the insurance plan can terminate the pharmacist contract,” Hoey said.
Federal lawsuits filed against United Healthcare, OptumRx and CVS Health allege these clawbacks impact a wide range of drugs and tend to target mostly those on high deductible health plans.
In one suit filed in Minnesota, the plaintiff, Megan Schultz alleges she got ripped off. She says she paid $165.68 for a generic drug with her insurance. Yet, if she paid cash, it would have only cost $92.00.
“We definitely do not want to be in that position as being the bad guy. Our goal is to get the safest medicine, the best medicine for the patient at the lowest cost,” Hoey said.
So what can you do? Medliminal, a medical billing advocacy group says just ask.
If you ask, “What’s cheaper, paying with my insurance or cash?” then the pharmacists can tell you.
Medliminal also tipped us off to the website GoodRX.com. It lets you type in your zip code to find the lowest price near you. Then you’ll know what you should be paying for that prescription before you get to the pharmacy. It also offers coupons for certain drugs.
Some states like Texas are trying to outlaw these clawbacks.
We reached out to United Healthcare, OptumRx and CVS health. CVS responded saying:
“Our PBM, CVS Caremark’s long-standing practice is not to engage in copay clawbacks, and we have no plans to implement clawbacks. If a PBM plan member’s copay for a drug is greater than the dispensing pharmacy’s contracted rate, it is not CVS Caremark’s practice to collect that difference from the pharmacy. If the pharmacy’s cash price is lower than the co-pay, the patient would be charged the lower price.”
UnitedHealthcare issued this statement:
“Pharmacies should always charge our members the lowest amount available under their benefit plans. The ‘clawbacks’ referenced in the class action suit had no impact on what members agreed to pay for prescription drugs per their benefit plans. We continue to believe this case has no merit and should be dismissed by the court.”
OptumRX did not respond to our inquiries.