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The Dose

The Great Big Prescription Drug Clawback

by John Norton | May 20, 2016

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Pharmacy benefit manager (PBM) corporations capitalize on the lack of governmental oversight to rake in profits, often at the expense of patients, health plan sponsors and pharmacies. One of the drug middlemen's most dubious practices are prescription drug "clawbacks," which New Orleans WVUE Fox News 8's investigative team of Lee Zurik and Tom Wright zeroed in on in a recent series.

The first segment, "Zurik: Copay or you-pay? Prescription drug clawbacks draw fire," exposes how patient copayments are now being manipulated to secure additional corporate profits at the expense of the consumer. Fox News 8 stumbled across a gross distortion of this practice in which the patient seems to be the only party making a financial contribution instead of sharing a percentage of the costs:


For example, doctors can prescribe the drug Sprintec to treat severe acne or for contraception. 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.

In these instances, instead of a traditional copay, patients are unknowingly footing the entire bill for their prescriptions, or, as it is cleverly described in the piece, a "you-pay," where the PBM corporations pay nothing and make a sizable profit off of the patient. Pharmacies are powerless to stop these shenanigans from happening:

"Whatever the insurance company/PBM tells us to charge as a copay, we have to charge the patient for that," our source says. "We cannot discount it, we cannot forgive it. Our computer calls their computer. They tell us charge the patient this much money."

What is especially frustrating for pharmacists are the gag clauses in their contracts with PBM corporations that necessitate these clinically-trained medication experts to grin and bear it. Not surprisingly, the story questions the legality of this practice on multiple fronts, including whether it runs afoul of the Affordable Care Act (or Obamacare, as it is also known).

The second segment in the series, "Zurik: United/Optum defends prescription 'overpayment program'," attempts to get satisfactory answers from PBM corporations as to why patients appear to be exploited to enrich PBM corporations. The main target is Humana and their PBM corporate subsidiary OptumRx, which was responsible for many of the prescription drug clawbacks in the previously-aired segment. They responded by admitting to their "overpayment" practice with a boilerplate statement:

There were follow-up emails with Fox News 8's investigative team that include questionable assertions from OptumRx that "A consumer doesn't pay any more with this program than they would without it." and "To be clear: this program ensures the customer pays the lowest amount possible within their plan."

Those declarations run counter to the documentation provided by pharmacists, who had to remain anonymous in the piece to avoid being retaliated against by the PBM corporations. Time after time, the patient was on the hook for a copay that exceeded the actual cost of the drug.

All too often, pharmacists' complaints about PBM corporations fail to move health plan sponsors or elected officials to take action. However, this is not another example of pharmacies being squeezed to the financial breaking point because of an unaccountable system. It's about patients being misled to help pad the bottom lines of PBM corporations. That cannot be allowed to continue. Pharmacists and patients need to amplify their concerns about questionable PBM practices every chance they get. Start by sharing the links that NCPA has provided via our social media channels; you can find the first, second, and third stories on our Facebook page, Twitter account, and Google+ page.