prescription drug "gag orders" and "clawbacks"

[tfudtuckerpucker]

I learned something new about prescription drug prices. It's called "gag clauses" and "clawbacks", which prevents pharmacists from revealing that the cash price for a drug may be lower than the copay.

“The clauses that we’re speaking about are really non-disclosure clauses, or as we call them gag clauses, which prevents the pharmacist from disclosing to a patient when the cash price for a medicine may be less than the copay on their insurance,”

"A middleman called a pharmacy benefit manager handles the prescription drug part of your health insurance plan on behalf of your insurer. For patients on certain insurance plans buying certain generic drugs, the benefit manager may charge a copay that exceeds a drug's cash price.

When the benefit manager charges that higher price, and then pockets a portion of the copay — that's a clawback. Because of clawbacks, many Americans are paying extra for some of the most commonly prescribed drugs in the country, pharmacists and other experts say.

Consumers rarely hear about clawbacks, pharmacists around the country told NBC News, because of so-called "gag clauses" in their contracts that they say often prevent them from discussing the practice with customers or from volunteering lower-cost options."

‘Gag Clause’ Keeping Pharmacies From Revealing Lower-Cost Drug Options


Could Your Health Insurance Be Costing You Money at the Pharmacy?

Here are the states that outlaw "gag clauses" or "clawbacks"

 

[Chuckanut]

My understanding is that the 'gag' is in place until you ask the pharmacist something like "Is there a cheaper way for me to buy this drug outside of my prescription insurance?" Once you ask, the gag is removed.

 

[gauss]

My understanding is that the 'gag' is in place until you ask the pharmacist something like "Is there a cheaper way for me to buy this drug outside of my prescription insurance?" Once you ask, the gag is removed.

In states with no laws in place regarding this, wouldn't this vary on a contract by contract basis?

Or perhaps there is some other type of law in place that governs disclosure when questions are asked in the fashion that you describe.

-gauss

 

[Breedlove]

I can explain what happened to me on this gag BS . Next month my DW is retiring so currently I am on her Insurance plan . I asked the lady at CVS , how much will my meds cost once I have to pay for them myself . So my co pay is 7.50 a month on one and 6.80 on the other . The pharmacist at CVS looks at her computer and quietly writes down 121.00 on one and 101.00 on the other . note these are 3 month supplies. I go to good RX and I can use a coupon at CVS for exactly what my copay is . I check Costco on line and my meds are less then my copay . She could have told me about the coupon but was gagged . Somebody needs to straighten out prescription drugs !

 

[MRG]

Tell me, this is a joke. I need a prior authorization from my urologist.My insurance won't look at the same numbers as the urologist I'm seeing. Therefore I don't need the tier one med for a $10 copay.

I can buy it for $750 monthly with goodrx, or $450 cash. However if I can convince my doctor to write the prescription slightly differently(1 50 mg. dose vs. 2 x 25mg) it is only $250 monthly through goodrx. This is nonsense.

Next year I'll be looking at much lower cost options, because the higher price ones are no better.

 

[Chuckanut]

Here's an interesting interview from the People's Pharmacy:
Show 1120.

IIRC, somewhere the guest mentions having to ask the pharmacist about lower prices.

https://www.peoplespharmacy.com/2018/05/03/show-1120-how-can-you-save-money-on-medicines/

You might not know that many pharmacists must abide by a gag clause that prevents them from volunteering information on how you could get a better price. She describes how it works and how you can get around it.

From Consumer Reports

To find those savings, you may have to ask pharmacists some direct questions. That’s because they’re sometimes bound by “gag clauses” in contracts with insurers that prohibit them from suggesting cheaper alternatives without first being directly asked by a consumer.

Emphasis mine.

 

[gauss]

Chuckanut - Thanks for the followup.

 

[Tadpole]

When the health insurance company contracts with a mail order pharmacy like Caremark or Express Scripts, does the insurance company negotiate the price or just subcontract their drug plan to whatever contracted price the mail order pharmacy gets?

 

[REWahoo]

Recently signed federal legislation has now outlawed these "gag clauses":

https://katv.com/news/local/new-fed...rmacies-to-create-transparency-of-drug-prices

[The] President... signed two bills into law on Wednesday that aim to relieve consumers of overpaying on prescription drugs.

One deals with Medicare and another with private insurance. Both pieces of legislation prohibit pharmacy benefit managers (PBMs) from restricting pharmacies from providing lower-cost drug price information to patients.

 

[target2019]

Sponsor and Co=Sponsors of the bill are listed here:
https://www.congress.gov/bill/115th-congress/senate-bill/2554/cosponsors

S.2554 - Patient Right to Know Drug Prices Act

 

[ERD50]

And passed 98-2 in the Senate. But I suppose we won't hear much about this partisan effort good news from the media. Controversy sells, I guess.

Anyone see the House vote roll? I couldn't seem to get there from that link.

-ERD50

 

[Freedom56]

This bill doesn't do anything. If you use your insurance to buy prescription drugs, you often pay more than cash using RxSave, GoodRX, or others especially for generic drugs. This bill doesn't do anything to solve that problem. It is still up to you to find the best deals. A pharmacist will ask for a group and bin number before they can price a cheaper option. This bill does not require that a pharmacist actively search for the cheapest option and provide that to you.

The biggest problem is the price disparity between drugs sold in this country and other countries like Canada. This bill does nothing to address that issue.

Here is some media coverage on this bill:

https://www.statnews.com/2018/10/10/trump-signs-gag-clause-bill/

 

[tfudtuckerpucker]

As I understand, the pharmacist was prevented from telling you if there's a lower price (cash, goodrx, etc) by the gag order from the pharmaceutical company. The bill outlaws these gag orders, but you still have to ask the pharmacist if there's a lower price. So pharmacists still might charge you the higher "insured" copay amount, unless you ask them, and now they can tell you if there's a lower price. But you have to ask (or just use the goodrx app, as I do).

 

[sengsational]

It outlaws an egregious business practice, but I agree that the overall effect will be minimal, especially given a simple change to allow non-US pharmacies would really make a difference.

 

[MRG]

As I understand, the pharmacist was prevented from telling you if there's a lower price (cash, goodrx, etc) by the gag order from the pharmaceutical company. The bill outlaws these gag orders, but you still have to ask the pharmacist if there's a lower price. So pharmacists still might charge you the higher "insured" copay amount, unless you ask them, and now they can tell you if there's a lower price. But you have to ask (or just use the goodrx app, as I do).

While goodrx has saved me thousands it's not always the cheapest coupon. Retail me not has some meds 50% cheaper than goodrx. Happy searching.

 

[travelover]

It outlaws an egregious business practice, but I agree that the overall effect will be minimal, especially given a simple change to allow non-US pharmacies would really make a difference.

Well sure, but it makes a nice sound bite, bragging point and doesn't upset the campaign donors.

 

[USGrant1962]

Well sure, but it makes a nice sound bite, bragging point and doesn't upset the campaign donors.

Yea, better they make no progress...

 

[6miths]

I'm sure that the 'free market' will sort this out.

 

[USGrant1962]

I'm sure that the 'free market' will sort this out.

Kind of hard to do when the medical field is probably the second or third most regulated industry after banks and public utilities...

 

[Lakewood90712]

We use Walgreens and CVS in CA., and for as long as I can remember, get the lower of co-pay or the cash price for generics. Might be a different thing for on patent meds.

 

[travelover]

Yea, better they make no progress...

Sorry, I guess I expect more for such an obvious problem.

 

[USGrant1962]

New proposal to required price disclosure in drug ads: https://www.washingtonpost.com/nati...ory.html?noredirect=on&utm_term=.32447abce7b5

 

[JoeWras]

While goodrx has saved me thousands it's not always the cheapest coupon. Retail me not has some meds 50% cheaper than goodrx. Happy searching.

At least now you can ask your pharmacist if this is the cheapest option. People are gonna have to speak up.

One huge problem we have in the USA is just taking what we get from the entire establishment. We have a culture of trusting these highly trained professionals or large hospitals and taking whatever they say as gospel.

I may make some retired medical pros mad when I say this, but we need to push back and ask questions about our care, including cost. I know I did when I got on a high deductible plan.

 

[MRG]

At least now you can ask your pharmacist if this is the cheapest option. People are gonna have to speak up.

One huge problem we have in the USA is just taking what we get from the entire establishment. We have a culture of trusting these highly trained professionals or large hospitals and taking whatever they say as gospel.

I may make some retired medical pros mad when I say this, but we need to push back and ask questions about our care, including cost. I know I did when I got on a high deductible plan.

+1

My PCP and I don't agree about much. I push back and she's not used to that. I want to understand why she tells me certain things and she's not used to someone asking why. I'll be damned if I'm doing something because of vague threats of what happened 50 years ago.

 

[samclem]

New proposal to required price disclosure in drug ads: https://www.washingtonpost.com/nati...ory.html?noredirect=on&utm_term=.32447abce7b5

This seems like a small but very welcome first step. Still, what does "list price" mean if nobody pays it?
What would happen if drug makers had to charge the same thing to every wholesaler/distributor, worldwide? To big pharmacy chains, Canadian pharmacies, the VA, everyone. They charge everyone, say, $2 for every 200mg tablet of Highprofimene. So, US consumers aren't subsidizing others, etc. And, then, this wholesale price would be the price disclosed in all advertising. That will rattle some cages.
I'd normally oppose this intervention in the free market, but there's no sense on pretending we have a free market today.