Congress has approved legislation that lifts a “gag rule” forbidding pharmacists from telling you when you can pay less for a prescription.
There’s something your pharmacist has been meaning to tell you.
In those talks about the goals of a certain medication therapy, the potential side effects, and how it may interact with other drugs, there’s been something important missing.
For years, there have been agreements between insurance companies and pharmacies that often included the middlemen known as pharmacy benefit managers.
Those agreements have specifically prohibited pharmacists from telling you if you were unnecessarily paying too much for your medicine.
Known as “clawbacks,” these arrangements have been tantamount to gag orders.
Even if paying cash for a prescription drugs was the cheaper route, pharmacists weren’t allowed to tell patients.
Instead, consumers paid their typical co-pay for many common generic and brand-name drugs, even if it cost the patient more for no other reason than that’s what insurance companies or their middlemen have agreed upon.
“We want to help our patients as much as we can, but there’s been some restraints, at least on the business side,” Mark Garofoli, PharmD, clinical assistant professor and director of the Experiential Learning Program at the West Virginia University School of Pharmacy, told Healthline. “If I had the opportunity to save you money, I couldn’t with a gag order in place.”
In essence, the arrangements have gone like this.
If a medication cost $5, but a patient’s co-pay was $20, a pharmacist was restricted by the gag order from telling the patient that if they paid cash instead of going through their insurance company, they could save $15.
But, as recently published research shows, this was a common practice that, over time, could result in thousands of dollars of overpriced medication.
“It’s business practices that make sense in certain business realms and it makes it more expensive for the patient,” Garofoli said.
That practice will soon change, thanks to new laws approved by Congress and signed by the president.
Researchers at the University of Southern California in Los Angeles examined data from 1.6 million commercially insured beneficiaries in 50 states.
In 9.5 million claims, 2.2 million — or 23 percent — overpaid for their prescription because their co-pay was more than the cost of the drug.
This occurred most often in generic drugs, such as the painkiller hydrocodone/acetaminophen. This commonly prescribed drug involved an average overpayment of nearly $7.
Of all the drugs, people typically paid an average of about $10 more on a prescription.
As a one-off, that markup doesn’t seem like it would break the bank, but it’s especially hard on people on fixed incomes or those taking medications long term.
All told, in 2013 alone, those overpayments equated to $135 million.
Considering these price differences are only done for the benefit of insurance companies or benefit brokers, the researchers found them unnecessary.
They recommended legislators investigate the pros and cons of these overpayments and gag clauses.
“Cost-related non-adherence is common and associated with increased medical services use and negative health outcomes. By raising patient costs at the point of sale, overpayments may exacerbate these effects,” the researchers concluded in a letter published in the Journal of the American Medical Association in March.
The day after the research appeared, members of Congress acted, introducing two bills to address the lack of transparency at the pharmacists’ counter.
Last month, federal lawmakers approved the two bills addressing what your pharmacists can and cannot tell you about your medication.
One “prohibits a prescription drug plan under Medicare or Medicare Advantage from restricting a pharmacy from informing an enrollee of any difference between the price, copayment, or coinsurance of a drug under the plan and a lower price of the drug without health-insurance coverage.”
The second created a federal ban on gag clauses after at least three states — Mississippi, South Dakota, and Virginia — had enacted similar laws.
“Multiple reports have exposed how this egregious practice has harmed consumers, such as one customer who used his insurance to pay $129 for a drug when he could have paid $18 out of pocket,” Sen. Susan Collins (R-Maine), the lead sponsor of the legislation in the Senate, said in a press release.
After the two bills passed with overwhelming support, President Donald Trump signed the bills into law on Oct. 10.
The laws won’t take effect until Jan. 1, 2020.
For those who take oaths to practice medicine, trust is a major concern in healthcare.
As Gallup polls show, those in the medical field — nurses, medical doctors and pharmacists — are viewed as the most ethical and trustworthy professions.
Since wearing a white lab coat is seen by many as wearing a cape, many pharmacists will be quick to jump at the opportunity of saving more patients some money while delivering them life-saving medicine.
Without the constraints of clawbacks or gag orders over them, Garofoli says patients can expect their local community pharmacist to start telling them about potential savings on their drugs sooner than the law officially takes effect.
“I would forecast the practice would change soon,” Garofoli said.