NYS Exposed: Insured patients could be paying too much for prescriptions

March 09, 2018 07:07 AM

If you take a prescription drug, this story affects you. You could be paying more for your medicines when a cheaper price is available. That’s because your co-pay for a generic drug may be more than the actual cost of the drug.  And your pharmacist is not allowed to tell you. Now pharmacists are fighting back. And Albany is listening.

You probably feel fortunate if your health insurance includes prescription drug coverage. But the truth is in some cases, it may be cost you more money because of a deal made between the pharmacy benefit manager, or PBM, hired by your insurer or employer.

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When you go to the pharmacy, if you have insurance you pay your pharmacist a co-pay, and you probably think your insurer pays the rest.  That's not how it works.  In the U.S., a PBM acts as a middleman.  A PBM is an organization that handles payments.  And this is really important - the PBM also negotiates the contracts.

"Many of the PBM contracts have gag clauses, confidentiality clauses which prohibit pharmacists from discussing the reimbursement of their prescription items," said pharmacist John Kroce.  He along with the Pharmacists Society of the State of New York has been pushing for legislation to eliminate the gag clauses.

Kroce knows that he is taking a chance by talking about the gag rule and practice known as clawback.  That’s when the PBM pockets the difference between what your drug costs and your co-pay. 

Say the actual drug cost is $20, but your co-pay is $40.  The difference goes to the PBM minus what's contracted to pay the pharmacy.  And if the drug maker offers a rebate on the drug, the PBM often pockets all that too.   So, as Kroce points out, the pharmacist cannot tell you that by paying cash and not filing insurance, you could save money. If they do and they're caught, they can be black balled.
"I will admit, we freely signed those contracts because without it people will not come to us without having us file their insurance," said Kroce.

"If you violate the contract you're out of the network. If you're out of the network you're out of business," said John McDonald.

He should know.  Assembly member John McDonald is also a pharmacist.  The Monroe County Medical Society also strongly supports the state legislation.  MCMS believes this is more than a pocketbook issue; it’s one of health. 

"There are stories of patients telling their physicians that they simply aren't taking medications or aren't refilling medications because they're having trouble affording them," said Christopher Bell, executive director of the Monroe County Medical Society.

The assembly and senate passed the bill without opposition.  Now the bill is in the hands of the governor.  If he signs it, New York will join five other states outlawing the gag rule.

But even if the bill becomes law, it’s still good practice for consumers to ALWAYS ask your pharmacist if the drug is cheaper if you pay cash and skip insurance.     


Deanna Dewberry

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