Pharmacy Benefit Manager Gag Orders and Clawbacks

We’re excited to present our second blog in a series meant to help youtake carewhen it comes to important arthritis health care and coverage issues. This week we’ll tell you about a practice some pharmacy benefit managers have been using called clawbacks, which affect the price of medications you pay at the pharmacy counter. Read on to learn more and see how the Arthritis Foundation is addressing the issue.

What are clawbacks?

A person who fills his or her prescription at the pharmacy may pay more for a prescription drug with insurance than if he or she had filled it without insurance. This can occur due to a“clawback,”a term used to describe the difference between the cash cost of a drug (purchasing a drug without insurance) and the copayment required by your health plan. That difference, the clawback, is often passed by the pharmacy back to the pharmacy benefit manager (PBM) as a profit. Unfortunately, this often occurs without the patient ever knowing they could avoid the higher copay by paying without insurance. A provision in the contract between the pharmacist and the PBM, known as a“gag order,”prohibits the pharmacist from disclosing cost information related to payment options.

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