Deena Flinchum
As I mentioned in my last column, there hasn’t been much in the way of new developments in Medicare of late.
Recently a rather significant development occurred which probably wasn’t noticed simply because most people were not aware of the problem that this development is meant to address.
Over the years, I have been asked many times why a drug might cost a different amount based upon the Medicare Part D drug plan and the pharmacy that the beneficiary chooses to use.
The simple answer is that pharmacy benefit managers, which are third-party administrators of prescription drug programs, are primarily responsible for devising drug formularies, signing contracts with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing claims.
These processes have been lacking in transparency to the people dependent upon these drug plans.
One of the more incomprehensible features of these contracts is the “gag clause”, a provision in contracts that insurance plans and their pharmacy benefit managers negotiate with pharmacies that prevent pharmacists from telling patients when they could pay less for a drug by buying it outright instead of using their insurance with its required copay or deductible.
Mid-May, the Centers for Medicare & Medicaid Services (CMS) sent a letter to companies that provide Medicare Part D prescription drug coverage, explaining that so-called “gag clauses” are unacceptable as part of the Administration-wide “American Patients First” initiative to lower prescription drug costs.
According to CMS Administrator Seema Verma, “President Trump and (Health and Human Services) Secretary Azar are committed to lowering drug prices, and CMS today took another important step to help patients who are feeling the pain. Many patients don’t know that some drugs are actually more expensive when they use their insurance. What’s worse is that some pharmacy benefits managers are preventing pharmacists from telling patients when this is happening, because they get a share of the transaction when the patient uses their insurance. Today we are taking a significant step towards bringing full transparency to all the back-end deals that are being made at the expense of patients.”
Pharmacists may now inform their customers that they might save money by purchasing their drugs without using their Part D insurance plans without being asked specifically about the savings.
I would suggest that anyone facing a high drug cost might want to ask the pharmacist directly if a lower price is available without using insurance just to be sure.
It is important to remember that any drugs purchased outside of the Part D drug plan will not count toward deductibles or affect the doughnut hole.
Deena Flinchum is a retired IT professional who has lived in the New River Valley since 2002. She serves on the board of the NRV Agency on Aging and as an RSVP volunteer. She also serves the Agency on Aging as an insurance counselor.
