NEW ORLEANS – Allegations of prescription-cost overcharging by pharmacy benefit managers and health-insurance companies have spawned at least 10 new lawsuits since early October, according to www.bna.com.

The lawsuits allege that benefit managers OptumRx and Humana Pharmacy Solutions Inc. have worked in concert with insurers including Cigna, UnitedHealth and Humana to overcharge customers by employing a “clawback” of the difference of a drug’s cost and the individual customer’s co-payment amount.

The plaintiffs also claim that these alleged overcharging schemes are being hidden from patients by the benefit managers, insurers and pharmacies.

“Discussion of how to claw back part of the copays seems more about lawyers trying to sue and settle for a big payday than actual patients who are harmed,” Devon Herrick, senior fellow for the National Center for Policy Analysis, told the Louisiana Record.

Many of the recent lawsuits have been filed in response to an investigation conducted by New Orleans television station Fox 8 into prescription-drug costs. The station said the investigation revealed that some insured patients would pay less for the prescription drugs in question if they had no prescription coverage at all.

Herrick said if patients are worried about whether their copays are more than the negotiated price of the drug in question, they can ask their pharmacists about the cash price or the insurance price, or do their own research on comparable prices.

“It doesn't take too much effort on the part of a patient to find out that Wal-Mart’s $4 30-day prescriptions (or $10 90-day prescriptions) are sometimes less expensive than a $10 or $20 co-pay on their drug plans,” he said.

Herrick said the “cash” price of medical services is often less than the insurers’ negotiated price of medical procedures, and, occasionally, even drug copays are slightly more than the negotiated price. Reasons for these price differences, he said, include whether someone has met their deductible or not and whether the pharmacy, clinic or physician is competing on price.

“Ultimately, I believe it should be up to the health-plan sponsor and their agents to design benefits,” Herrick said.

According to Herrick, PBMs and health plans, including both insurers and employer plans, establish policy about formularies, copays and other aspects of a drug plan.

Herrick said industry data show that nearly one-quarter of prescriptions have no copay, about one-third have a copay of $5 or less, and nearly 75 percent have copays of $10 or less.

“Tiered copays are used by health plans and drug plans to create incentives to steer enrollees to the appropriate drug, which is usually a generic,” Herrick said. “On the individual level, this sounds like small potatoes. A generic may cost the insurers $2 less than the copay; a brand-name drug may cost the insurers $200 more than the copay.”

“Patients should not have to pay more than a network drugstore’s submitted charges to the health plan,” the Pharmaceutical Care Management Association told the Louisiana Record in a statement.

The association said PBMs are projected to save Louisiana’s employers, unions, government programs and consumers $9.5 billion on drug benefit costs over the next decade.

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Organizations in this Story

National Center for Policy Analysis
14180 Dallas Pkwy
Dallas, TX 75254

Pharmaceutical Care Management Association
325 7th St NW
Washington, DC 20004

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