Copay or you-pay? Prescription drug clawbacks draw fire


Isa Zorrilla, 11, lugs around quite a heavy load of textbooks and binders. It seems to be paying off – she’s mostly an “A” student.

 “My favorite subject is reading,” Isa tells us.

Her favorite book is “Counting by 7s”. “It’s about a girl or an orphan,” Isa says. “She was adopted at first and then her parents die. And you see how she changes the world.”

Isa is finishing 5th grade at New Orleans’ Lusher Elementary. And we wanted to see if we could teach her a new word.

It’s a word you likely hear on every trip to the doctor or the pharmacy: copay. Isa got an “A” in our pop quiz by figuring out the definition on her own.

“If someone would charge you, you’d pay like some of it to them,” she answers, “and then someone else would pay some of it.  Like copilot – copay.”

The actual definition is something like this: A copay is a type of insurance payment where the insured pays a specified amount, and the insurer pays the remaining costs.

“It’s pretty simple,” Isa says.  “The insurance policy paying some of it and not all of it… hopefully you don’t pay too much.”

But our investigation has found, in some cases, there’s only one payment being made – by you.

One source for our investigation, a New Orleans-area pharmacist, asked us to hide his identity.  Contracts with pharmacy benefit managers, or PBM’s, prevent him from talking publicly.

But documents that multiple pharmacists provided to FOX 8 News show, in some cases, companies are charging copays that exceed the customers’ costs for their drug.

Pharmacists call it a clawback – the company is essentially clawing back money from you and, our source tells us, you probably don’t even realize it’s happening.

“They have no idea,” the pharmacist says.

For example, doctors can prescribe the drug Sprintec to treat severe acne or for contraception. One document given to FOX 8 spells out how the clawback works.  It shows the cost of the drug, including tax and pharmacist’s fee, is $11.65.

But that same document reveals the pharmacy had to charge the customer a copay of $50 for the Sprintec. The remaining $38.35 was sent back to the insurance company’s pharmacy benefit manager.

Read the full story here