Many people assume that if they have insurance, a copay for a prescription costs less than the drug’s actual cost. But according to a recent report from the University of Southern California, copays actually cost more than the retail price of the drug almost 25 percent of the time. For example, if a patient’s insurance copay for a drug is $10, it’s possible they would pay only $8 (or less) if they didn’t use insurance.
The USC study analyzed 9.5 million prescriptions filled during the first half of 2013. It showed an average overpayment of $7.69, totaling $135 million that year. That money, known as a “clawback,” usually goes to the pharmacy benefit managers (PBM), the middlemen that strike deals between insurance companies, drug companies and pharmacies.
But that’s not all: some of the contracts that pharmacists sign with the PBMs forbid them from voluntarily telling a customer they could save money if they paid out of pocket. Several states have begun to outlaw these “gag clauses,” and Congress is considering legislation, too.
Three large PBMs—CVS Caremark, Express Scripts and OptumRX—control more than two-thirds of the market. The PBMs say the deals they facilitate help bring down the overall cost of drugs. The Pharmaceutical Care Management Association, which represents PBMs, says it supports consumers paying the lowest prices and does not condone gag clauses.
We’re asking: Have you ever discovered your prescription is cheaper if you don’t use your insurance? The PBS NewsHour Weekend reporting team is gathering stories about the high cost of prescription drugs and patients’ experiences at the pharmacy. Submit your story using this simple form.