If you have private insurance and pay a co-pay at the pharmacy, you may be spending more than you need to for many common medicines.
A variety of generic drugs for common conditions like diabetes, high blood pressure, high cholesterol and arthritis cost less than the co-pay for many insurance plans, but the pharmacist is barred from telling you. Forgoing an insurance card and paying cash may be a much better option, depending on your specific prescription, co-pay and deductible.
“There’s not a lot of understanding out there – which is understandable – about how this system works,” said Michelle Rivas, a vice president of the Center for Advocacy at the California Pharmacists Association. “You go, you pay and you have no idea that you could get it for a lesser dollar amount.”
There’s a middleman between your insurance company and your local pharmacist. A “pharmacy benefit manager” processes all of your claims that have to do with prescription drugs. When you hand over a co-pay at the drug counter, that goes to the middleman.
But here’s the catch. The co-pay is often more than the retail price of the drug if you pay cash directly to the pharmacy.
“A patient will pay $30 when they could’ve paid $1.50 had they just paid cash versus using their insurance benefit,” Rivas said.
But if the pharmacist knows this, why don’t they tell you?
The middleman puts what’s called a “gag clause” in their contracts with pharmacies that bar them from offering a cash price to clients.
Pharmacies that break contract can be audited or even lose their contract with the benefit manager, something Rivas said would be crushing for a small business.
The association offered one case in Orange County as an example, where a pharmacist spoke out about the policy and was promptly served with a cease and desist letter warning against disclosing price information.
But there is a way around this. Be your own advocate.
As you long as you initiate the conversation, your pharmacist isn’t stopped from your questions.
“It would be in their best interest to get in the habit of when you’re picking up prescriptions to ask the pharmacist if there’s a less expensive alternative to them for purchasing their medications,” Rivas said.
Bakersfield pharmacists polled by Eyewitness News expressed deep frustration with the policy, but their own contract situations prevented them from speaking out on the record.
They have placed considerable hope in a piece of legislation that aims to outlaw gag clauses that hurt consumers.
Assembly Bill 315 passed the assembly last year with broad bipartisan support, but has not yet been voted on this year in the state senate. The California Pharmacy Association is confident the bill will pass, noting the changes happening in the senate aren’t related to partisan differences, but simple semantics.
Devon Mathis, Rudy Salas and Vince Fong each voted for AB 315 and Tom Lackey, who represents Kern’s desert communities, voted no.
Eyewitness News offered all four men the opportunity to comment on their vote and only Mathis responded, issuing the following statement:
“One of the main reasons why I supported AB 315 was centered on the more appropriate regulatory oversight within the Department of Managed Health Care, rather than the State Board of Pharmacy. In addition, this measures increases transparency with regards to drug acquisition costs, rebates, and rates. The existing system has placed a conflict of interest in pharmacy benefit managers, which ultimately reduces transparency. This measure helps the consumer understand the true cost of prescription drugs.”