Ask about pre­scrip­tion costs

Phar­ma­cists barred from talk­ing prices, but avoid pay­ing too much

Albany Times Union - Sunday - - BUSINESS - By Matthew Perrone As­so­ci­ated Press Washington

“Do you have pre­scrip­tion in­sur­ance?”

It’s one of the first ques­tions con­sumers hear at the phar­macy counter, and many hand over their in­sur­ance cards in the hopes of get­ting a good price. But some­times us­ing in­sur­ance can ac­tu­ally cost more — and even pre­vent the phar­ma­cist from say­ing so.

That’s be­cause of so-called gag rules, which bar phar­ma­cists from telling pa­tients when they could save by pay­ing cash in­stead of us­ing in­sur­ance. The rules — set by com­pa­nies that man­age pre­scrip­tion plans — are get­ting new scru­tiny af­ter Pres­i­dent Don­ald Trump sin­gled them out for crit­i­cism in his plan for low­er­ing drug prices.

“This is a to­tal rip-off and we are end­ing it,” Trump said of the prac­tice.

Here are some key points and tips to avoid over­pay­ing for pre­scrip­tions:

Com­mu­ni­ca­tion con­straints

The gag rules are in­cluded in con­tracts be­tween phar­ma­cies and phar­macy ben­e­fit man­agers, com­pa­nies that are hired to hold down pre­scrip­tion costs for in-

sur­ers and em­ploy­ers. Some con­tracts limit the in­for­ma­tion phar­ma­cists can share, in­clud­ing when a pa­tient’s co-pay ex­ceeds a drug’s cash price.

“When it comes down to mak­ing sure the pa­tient can af­ford their med­i­ca­tion, the gag clause pre­vents us from hav­ing that con­ver­sa­tion so they can make the best in­formed de­ci­sion,” said Randy Mc­donough, an Iowa phar­ma­cist.

There are no of­fi­cial sta­tis­tics on the re­stric­tions, but a 2016 in­dus­try sur­vey found that nearly 20 per­cent of phar­ma­cists were lim­ited by gag clauses more than 50 times per month.

Andy Soileau, a Louisiana phar­ma­cist, re­cently tes­ti­fied be­fore state law­mak­ers about the is­sue. He cited an ex­am­ple of a cus­tomer who was re­quired to pay a $50 co-pay for generic birth con­trol pills that would have cost $18 with­out in­sur­ance.

Last month, Louisiana be­came the lat­est of nearly 20 states to ban the re­stric­tions.

Cheaper drugs, higher fees

Amer­i­cans wind up over­pay­ing for pre­scrip­tions be­cause many medicines are now avail­able as low­cost gener­ics.

Nearly 90 per­cent of pre­scrip­tions filled in the U.S. are for gener­ics drugs, some of which cost as lit­tle as $4. Mean­while, the typ­i­cal U.S. em­ployee faces an $11 co-pay to fill a generic pre­scrip­tion, ac­cord­ing to a Kaiser Fam­ily Foun­da­tion anal­y­sis. The co-pay is higher for brand-name drugs, av­er­ag­ing $33 for pre­ferred brands.

Many phar­macy ben­e­fit man­agers re­quire phar­ma­cists to col­lect the full co-pay, re­gard­less of a drug’s cash price.

Stephen Schon­delmeyer, who stud­ies phar­ma­ceu­ti­cal eco­nom­ics at the Univer­sity of Min­nesota, said the phar­macy ben­e­fit man­agers tell phar­ma­cists: “If we catch you telling pa­tients you can buy this cheaper for cash we will kick your phar­macy out of our net­work.”

A re­cent study in the Jour­nal of Amer­i­can Med­i­cal As­so­ci­a­tion es­ti­mated that for nearly 25 per­cent of pre­scrip­tions filled, co-pays were higher than what in­sur­ers ac­tu­ally paid for the drugs. That ex­tra money is kept by in­sur­ers or the phar­macy ben­e­fits man­ager, ac­cord­ing to the au­thors.

In­sur­ers have long said that co-pays are used to re­duce in­sur­ance pre­mi­ums for all, bring­ing down over­all health costs. And the in­dus­try group for phar­macy ben­e­fit man­agers says it op­poses gag clauses and poli­cies that lead to over­pay­ments.

“We sup­port the pa­tient al­ways pay­ing the low­est cost at the phar­macy counter, whether it’s the cash price or the co-pay,” said the Phar­ma­ceu­ti­cal Care Man­age­ment As­so­ci­a­tion, in a state­ment.

Some of the largest phar­macy ben­e­fit man­agers, in­clud­ing Op­tum, say they do not use gag rules.

“If a phar­macy is not pro­vid­ing their cash price to our mem­bers they are in vi­o­la­tion of their con­tract,” said a spokesman for the com­pany, which pro­vides phar­macy ben­e­fits to 65 mil­lion peo­ple.

What you should do

Con­sumers can make sure they aren’t over­pay­ing for drugs. Ask the phar­ma­cist for the cash price of the drug. Gag clauses pro­hibit phar­ma­cists from vol­un­teer­ing this in­for­ma­tion, but they can re­spond if asked di­rectly. Use web­sites or apps like Goodrx to re­search cash prices.

Rich Pedroncelli / As­so­ci­ated Press

For nearly 25 per­cent of pre­scrip­tions filled, co-pays were higher than what in­sur­ers paid for the drugs, ac­cord­ing to a re­cent study.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.