Could Pharmacy Benefit Managers Be Increasing Drug Costs?

PBMs could potentially be raising drug costs through remuneration fees and copay clawback fees even though they claim to reduce costs.

A recent survey suggests that pharmacists are facing misleading and confusing fees from pharmacy benefit managers (PBM) that could harm pharmacies and patients.

The survey, conducted by the National Community Pharmacists Association (NCPA), included 640 pharmacists, and explored the effect of direct and indirect remuneration (DIR) fees and copay clawback fees. Sixty-seven percent of respondents indicated that no information was provided about DIR fees regarding how much will be collected and when the fees will be collected.

Approximately 73% of pharmacists said that they never received an itemized list about what fees are being collected for each claim. A majority of respondents found DIR fees in commercial plans, although they started in Medicare Part D, according to the study.

Eighty-seven percent of pharmacists said these fees affect patient care and the ability to continue their business. These fees can cost thousands per month.

Copay clawbacks, which are when pharmacies are required to charge patients higher copays, with the excess money taken back by the PBM. This was experienced by 83% of respondents at least 10 times within the past month, the survey found.

"Patients purchase insurance with the presumption that they will save money using the plan's designated health care providers," said NCPA CEO B. Douglas Hoey, RPh, MBA. "Copay clawbacks turn that logic on its head. A copay becomes a full pay, and then some."

Approximately 59% of pharmacists said they encountered a gag clause at least 10 times in the last month. The gag clause prohibits pharmacists from revealing to the patient that it would be cheaper to buy the medication without insurance, according to the study.

However, if the patients ask, pharmacists are allowed to tell them.

"DIR fees and copay clawbacks are serious problems for pharmacies and patients alike. PBM corporations are inserting costs into the system on virtually everyone in order to fuel their profits and reward shareholders," Hoey concluded. "Government officials and health plan sponsors must insist on greater transparency and oversight of these practices to ensure that plan costs and premiums go to their intended purpose: taking care of patients.”