If you have a copay, chances are you’ve overpaid for a prescription at some point.
That’s because an insurance copay can be more expensive than the cash price of the drug — more expensive than if you’d had no insurance and paid out of pocket.
And because of “gag clauses” in contracts between pharmacies and the insurance claims payers, you’d never know this. Until now.
In a bill Gov. Phil Bryant signed in March, which will take effect in July, insurers can no longer prevent pharmacists from telling patients whether their copay is higher than the cash cost of their medication.
A couple of weeks ago, Valerie McClellan went to the Kroger pharmacy in Madison to pick up a prescription for an allergy medication. She learned the copay was going to cost her $50.
“I must have gone ‘whoa,'” McClellan said, because the pharmacist did something unusual: he told McClellan how she could get the medication for just $10 by using a coupon online.
“At the time, I remember thinking, ‘Wow, I’ve never had a pharmacist tell me where I can go to save some money,'” she said.
Related: Coordinating prescription refills in Mississippi is about to get easier
Insurance copays don’t take into account the actual price of the medication, so a beneficiary will pay the same amount — whether $5, $25 or $50 — even if the drug is less expensive.
“The consumers, they think that they have insurance, therefore the insurance company or the pharmacy benefit manager is helping lower their drug costs,” said Robert Dozier, executive director of the Mississippi Independent Pharmacies Association. “And in some cases, it’s not.”
In a study released in March, customers paid copays that effectively overcharged them for medications nearly one-fourth of the time.
The analysis, conducted by University of Southern California Schaeffer Center for Health Policy & Economics, included 1.6 million people who paid for 9.5 million prescriptions.
The study’s authors are calling it the “Copay Clawback Phenomenon” because the overpayments — the difference between the copay and the cash price of the prescription — go to the pharmacy benefit manager, the middlemen that pay drug claims for insurance companies. These include Express Scripts, CVS Caremark and OptumRx.
And until a few weeks ago, many pharmacists in Mississippi couldn’t tell the patient what was going on.
Pharmacy benefit managers in the state were able to include “gag clauses” as part of their contract, so pharmacists couldn’t notify a patient if the cost of their prescription was cheaper than their copay, even if they asked.
With a bill this legislative session, Mississippi joined 14 states that have enacted laws prohibiting these gag orders.
“It gives us an extra tool to help people without the fear of retribution,” said Jackson’s Beemon Drugs owner Lester Hailey. “We’re proud of the state for passing this and giving us the freedom to save some money for the consumers. I think it’s a great step.”
Express Scripts and CVS Caremark both told Clarion Ledger they do not endorse the use of gag orders.
OptumRx and CVS Health have both faced lawsuits alleging they use the clawbacks. OptumRx told NBC it supports charging the lowest amount to customers while CVS has outright denied the allegation.
Several other insurers face lawsuits regarding the alleged scheme.
On March 8, Gov. Phil Bryant signed the Prescription Drugs Consumer Affordable Alternative Payment Options Act, sponsored by House Public Health and Human Services Chairman Sam Mims, R-McComb, and others, encouraging pharmacies to communicate with customers about cheaper payment options.
“I feel awesome that that’s changed now, that you can have that conversation with your pharmacist, and they can assist you,” McClellan said.
Hydrocodone, an opioid, is the most prescribed medication in Mississippi. In the Schaeffer Center study, patients were overcharged for the pill more than one-third of the time. For folks whose copays were higher than the cost of hydrocodone, the average upcharge totaled $6.94.
For other drugs, the average overpayment was much higher — $14.56 for the cholesterol medication Crestor, $17.55 for fluticasone propionate nasal spray and almost $20 for bronchitis medication Ventolin.
For four drugs — zolpidem tartrates like Ambien, cholesterol medication simvastatin, calcium blocker amlodipine besylate and prednisone steroid — patients were overcharged more than half of the time.
Around the time McClellan bought the allergy medication, she said she also paid out of pocket, instead of a copay, for her husband’s heart medication, saving her roughly $30.
Add it up, McClellan said, and that’s a monthly water bill. Or a tank full of gas.
Had the pharmacist not told her about other payment options, McClellan said she wouldn’t have known to ask.
“We just accept that insurance is this, my copay is this, and that’s it,” she said. “We’ve been taught we don’t have any power over what doctors charge, what medications cost. We just pay it.”
That may be starting to change. In an often difficult-to-navigate health care system, Mississippians can save money by asking their pharmacist if their copay is higher than the out-of-pocket cost of their prescription.
This article is about prescription prices and the graphic that they use at the top of the article HYDROCODONE… and if you do a word search in the 800+ word article you will find the word HYDROCODONE – TWICE IN THE ENTIRE ARTICLE !!! – in the same sentence.
It would appear that some/many in the media will pull in a opiate – somehow – into just about any article that deals with just about anything that has to do with prescriptions.
Filed under: General Problems
Geee,,maybe its that 433 million kolodyn got our tax money to be spent on their ,”propaganda media campaign,”Any way to find out where OUR money went and who?maryw