When you fill a prescription covered by your insurance, you probably assume that the retail price is higher than the copay that comes out of your pocket. That’s the point of insurance, isn’t it? You pay a monthly premium, and in exchange, the insurer helps pay for your doctor visits, prescription drugs and other medical expenses. This is what most people assume, but in the case of prescription drug clawbacks, it isn’t always true.
What Are Prescription Drug Clawbacks?
The practice of prescription drug clawbacks refers to insurers or their pharmacy benefit managers charging a copay that’s higher than the cost of the drug.
For example, let’s say your copay for a certain prescription is $15. You don’t know how much the insurer pays, but you assume it’s more than $15, and that you’re receiving a discount by using your insurance. In reality, the insurer actually pays only $10, pulling in a tidy profit of $5 per prescription.
In other words, you’d be better off paying for the prescription on your own, without using your insurance.
The above numbers are only hypothetical examples to illustrate how the practice works. Real-life examples could result in unnecessary costs that are much bigger than $5.
The Pushback Against Prescription Drug Clawbacks
If this practice makes you mad, you’re not alone.
According to Bloomberg BNA, several class-action lawsuits have been filed against insurers and pharmacy benefit managers. Meanwhile, politicians are working on new legislation that would address the problem. U.S. Senators Susan Collins, Claire McCaskill and Debbie Stabenow have introduced two bipartisan bills to help consumers avoid paying too much for prescriptions – the Patient Right to Know Drug Prices Act and the Know the Lowest Price Act.
The proposed bills would not necessarily ban the practice of drug clawbacks, but they would ban gag clauses that stop pharmacists from telling customers that they could save money by not using their insurance plan. Currently, pharmacists who warn their customers about this can face penalties for doing so.
Protect Yourself
While we wait to see the outcome of current lawsuits and proposed legislation, consumers should protect themselves.
When filling a prescription, ask how much it would cost without insurance. Remember that, because of gag clauses, pharmacists may not be able to offer this information on their own even if they want to. You need to ask.
If the prescription is cheaper without insurance, buy it that way. You can also try checking the price at different pharmacies to find the best deal.