Pharmacy Clawback

A pharmacy clawback happens when a patient's copay at the counter is higher than the total the plan and PBM agreed to pay for the drug, and the PBM takes the extra back from the pharmacy. Say the drug costs the pharmacy $6, the plan's contracted price is $8, and the plan's copay for that tier is $20. The patient pays $20, the pharmacy keeps $8, and the PBM claws back $12. The patient paid more than the drug was worth, and the pharmacy was until recently forbidden by contract from saying so.

That contract clause was the gag clause. A University of Southern California study of 2013 claims found the patient's copay exceeded the drug's full cost on about 23 percent of prescriptions, with the overpayment averaging $7.69 on generics. Congress banned pharmacy gag clauses in 2018, so a pharmacist can now tell you when paying cash would be cheaper than using your insurance. What was not banned is the clawback itself. The overpayment still happens; you just have the right to be told and to pay cash instead. The catch with paying cash is that the money usually does not count toward your deductible unless your state has a law saying it must, which Texas does for state-regulated plans.

The takeaway: at the counter, ask one question every time: "Is it cheaper if I don't use my insurance?" The pharmacist is allowed to answer now. For a generic on a fixed copay, the answer is yes more often than you would think.