RX for Savings: Clawbacks, gag clauses keep lower drug prices secret

MEMPHIS, Tenn. — Sam Cooper is one of the many Americans who's faced a prescription price hike.

"After a change in our coverage it went from $15 a month for a 90 day supply to $300 a month for a $90 day supply," he said.

That's a difference of $285, but with zero explanation.

"I was flabbergasted, totally," Cooper said. "I called the insurance company. I asked them why, and they just either couldn't or wouldn't answer that."

"Insurance doesn't pay for what you would expect it to," Phil Baker, who runs the Good Shepherd Pharmacy, said.

He explained how secret deals often keep insured customers in the dark and paying higher prices.

"It all falls back on the pharmacy benefit provider, because they negotiate the prices," Baker said. "They also contractually bind the pharmacy so they can't tell the customer what the real price is."

A recent survey of community pharmacists revealed they were seeing a big increase in what's called clawbacks.

"It's where they intentionally over charge patients and tell the pharmacy to send us that extra money," Baker said.

According to the survey, it typically happens with high deductible plans, so patients just think they're paying for the cost of the drug before their insurance kicks in.

In reality, they're paying much more and the PBM"s are clawing back to the extra.

"Basically, you wouldn't know it. You would have no idea that you're actually paying more than what the retail pharmacy charges," Baker said.

Consumer Reports Lisa Gill says the barrier to learning about the cheaper cash price comes from what's called a "gag clause."

"It prohibits pharmacists from offering that lowest possible price unless the consumer asks," Gill said.

That's sort of what Cooper did. He called the drug manufacturer and found a discount program

"I can actually get the patent brand, a 90 day supply, and it cost me nothing," he said.

Some states have enacted law banning gag clauses and other are working to ban clawbacks too.

Experts say the key, whether you have insurance or not, is to ask your pharmacist for the lowest possible price.