Like an evil chess Grandmaster, PBMs are incredibly adept game players, exercising diabolical patience and foresight as they craft the long-term cons they sell as "saving money" on behalf of consumers and plan payers.
Pharmacists are well aware of the complicated tactics that make up the PBM playbook and result in unnecessary millions charged to end payers every year.
Knowing patients and end payers are being ripped off is one thing. Calling attention to the rip off is an entirely different - and extremely risky - matter. But a PUTT member pharmacist is taking a new approach: documenting the perpetuated spread pricing that occurs between the deductible and benefit phases in a patient's plan, and reminding patients they have the right to request a "receivables statement".
What is "Perpetuated Spread Pricing"?
Imagine this scenario: you're a consumer with normal prescription drug coverage through your employer. It's late January, time for your monthly medication refill. You go to your local drugstore, the pharmacist inputs the script and updates your insurance as per usual. Because you're in the deductible phase, you're charged the full copay and the PBM bills your plan at the contracted rate. You and your health plan repeat this process monthly until your deductible is met and your copay is $0.
Now imagine your coworker, a member of your same insurance plan, who takes the same medication and dosage but has met their deductible a little earlier than you. They have a $0 copay and the health plan pays the same contracted rate as before, right?
When the pharmacist inputs your co-worker's information, it returns pricing based on what should be "contract pricing" but after the deductible is met, the system automatically prices that same medication at "MAC pricing".
This behind-the-scenes switch allows PBMs to continue to charge the health plan the higher contracted rate, but reimburse the pharmacy substantially less, resulting in greater spread - and therefore increased profits - to the PBM.
When the patient is in the deductible phase, they very often pay an average of 235% more for medication that, when the deductible is met, the PBM is now indexing against MAC, and now paying itself more by charging the health plan the contracted rate and reimbursing the pharmacy for the lower-priced MAC rate.
Perpetuated spread pricing is a direct violation of the contract between the PBM and the consumer's insurance plan, especially since the medication price charged to the consumer between the deductible and benefit phases is substantially different. Unless two patients with the exact same prescription under the exact same group insurance plan come into the same pharmacy to fill their identical prescriptions at the same time, no one might ever catch on to the discrepancy.
It's convoluted consumer defrauding at its finest.
Pharmacists legally aren't allowed to disclose this level of information to consumers without risking multiple lawsuits from the PBMs and insurers. The only way for consumers to actually ensure they're not being overcharged is under new state & federal anti-gag clause legislation.
Most states have recently passed anti-gag clause legislation. This same legislation allows patients to request a receivables statement when they fill a prescription. If a consumer were to do this each time they filled their prescriptions, they could see actual prescription charges and could compare prices against what their plan says they should be charged.
The PUTT member pharmacist discovered this new level of consumer fraud because it was his plan - and one of his co-workers on the same medication - who were charged the different amounts for the same prescription. He filed a formal complaint with his state's department of insurance and was told he "wasn't considered a consumer" and therefore the complaint was thrown out.
PUTT encourages members to review your state's anti-gag clause legislation to check for the receivables statement language, and then inform patients of their right to know how much they and their health plan are being charged for their prescriptions.