Patients can often pay less for their generic medications if they sidestep insurance and pay out of pocket, but contracts with pharmacy benefit managers forbid pharmacists from telling customers this information, reports Chicago Tribune.
Here are five things to know.
1. Eric Pusey, who owns Medicap Pharmacy in Olyphant, Penn., says his PBM contracts bar him from informing customers when they are paying a copay that's higher than the actual cost of their generic medicine. He only tells customers about the money-saving strategy if they ask, according to the report.
"Some of them get fired up," he told the Tibune. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate."
2. The extra money from the higher copays is funneled back to the PBMs in what the industry refers to as a clawback. Clawbacks can be as small as $2 per prescription, or as much as $30. The payments boost profits for PBMs by hundreds of millions of dollars and have spurred at least 16 lawsuits since October, according to the report.
3. A Feb. 10 receipt obtained by Bloomberg showed a customer at an Ohio pharamacy paid a $15 copay for 15 milligrams of the generic stomach medicine pantoprazole, which the pharmacist bought for $2.05. The pharmacist was repaid $7.22 — giving him a profit of $5.17 — and the remaining money went back to the PBM, according to the report.
"There's this whole industry that most people don't know about," said Craig Raabe, a Connecticut lawyer who represents defendants filing lawsuits against the PBMs. "The customers … are paying a $10 copay for amoxicillin, having no idea that the PBM and the pharmacy have agreed that the actual cost is less than a dollar, and they're still paying the $10 copay."
4. The National Community Pharmacists Association surveyed its more than 22,000 members and found 83 percent of 640 independent pharmacists reported at least 10 clawbacks a month. Some pharmacists estimate clawbacks occur in 10 percent of all transactions, according to the Tribune.
5. The Pharmaceutical Care Management Association, a PBM trade group, said it anticipated larger scrutiny over its role in high drug costs and seeks to present its case "vocally and effectively," according to the report.
"Patients should not have to pay more than a network drugstore's submitted charges to the health plan," Charles Cote, a spokesman for the lobby group, told the Tribune.
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