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Drug Plans Profit from “Clawbacks”

Two separate journalist investigations in 2016 have highlighted the little known practice of “clawbacks” by pharmacy benefit managers (called “PBMs”) that administer drug plans.

Drug plans often have required dollar amounts (“copays”) that are charged to patients when filling a prescription covered by the plan. Sometimes, the price of the drug is actually less than the copay.

At the pharmacy counter, patients pay their share of the cost — the copay — as set by their PBM and insurance plan. Days or weeks later, the PBM firm takes back a portion of that patient payment from the pharmacy after the PBM determines what it will actually pay for the drug — a practice sometimes called a “clawback.” That money does not go to the consumer but is generally kept by the PBM.

TV station WVUE FOX 8 in New Orleans highlights an example of a drug called Sprintec:

One document given to FOX 8 spells out how the clawback works.  It shows the cost of the drug, including tax and pharmacist's fee, is $11.65. But that same document reveals the pharmacy had to charge the customer a copay of $50 for the Sprintec. The remaining $38.35 was sent back to the insurance company's pharmacy benefit manager.

To protect our members from being overcharged in this way, conventional prescription drug copays can be replaced with a “maximum copays” or “capped copay.” Under this design members are charged the lesser of the price of the drug (called the “discounted network price”) or the capped copay amount.

Links:

Filling A Prescription? You Might Be Better Off Paying Cash (Kaiser Health News, June 24, 2016)

Copay or you-pay? Prescription drug clawbacks draw fire (FOX 8 WVUE New Orleans, May 4th 2016)