If there was a way to get your medication cheaper, wouldn’t you want to know?
Chicagoan Shalunda Williams would.
“I have one [prescription], out-of-pocket, is $300 with insurance,” Williams said.
“There are times when a prescription can be cheaper to the consumer without the insurance,” said one Chicago-area pharmacist who has been in the business for more than 30 years. He only agreed to talk to NBC 5 Investigates if his identity could be protected. But, he said, “It can be less, a lot less, yes.”
That’s a surprise to consumers like Janie Trigo from Cincinnati, Ohio.
“I had no idea,” Trigo said. “I just assumed I was getting the best price” by using insurance.
You may be paying more because of a practice called “clawbacks,” where money is clawed back by middlemen known as Pharmacy Benefit Managers, who negotiate the price your insurance company pays for a drug.
“Some plans claw back on all brands and generic. Some claw back only generics. Some — brands only. It totally depends on plan the patient has,” the pharmacist said.
These contracts can include a gag clause, prohibiting your pharmacist from letting you know if you could pay less by not using your insurance.
“It’s a bad practice,” said Kurt Florian, the CEO and President of the Epilepsy Foundation of Greater Chicago. ”It’s unconscionable that it exists.”
A dozen states have outlawed clawbacks outright, or, at the very least, the gag clause. Illinois is not one of them.
“We are going to be reaching out to legislators in Illinois to see who is willing to sponsor legislation to get rid of this bad practice,” Florian said.
One way consumers can protect themselves is to speak up. There is one question you need to ask when picking up your medication: “Can I get this cheaper without my insurance?” That unlocks the gag clause, and the pharmacist can answer.
“They can come in and ask what is the cash price, and then go from there,” the pharmacist said.
The Pharmaceutical Care Management Association represents America’s Pharmacy Benefit Managers. When NBC 5 Investigates asked about the gag clause, the association responded with the following statement:
“Pharmacy benefit managers (PBMs) typically reduce prescription drug costs by 30 percent for more than 266 million Americans enrolled in private and public plans, most notably Medicare Part D. PBMs use their substantial scale and expertise to negotiate aggressive rebates, discounts, and other price concessions from drug manufacturers and drugstores on prescription drugs. We support the patient paying the lowest price available at the pharmacy counter for the prescribed drug.”
While the practice of clawbacks continues, the Illinois pharmacist watches in disgust.
“I’m here because I want to help the patient. I’m here because I see an injustice to the consumer and to the pharmacy profession,” he said.
Bottom line: Don’t assume that going through your insurance will get you the best price on your prescription medication. If you simply ask for the lowest price a pharmacy can offer, that could reduce what you pay.