Today, we’re talking about “clawbacks.” And yes, they are as scary and painful as they sound.
Before we explain what’s going down in the Buckeye State, here’s a refresher on PBMs. These companies manage prescription drug benefits for insurance companies, and they act as the middlemen connecting insurance plans, wholesale pharmaceutical sellers, employers, pharmacies, and patients
But according to a recent article in The Columbus Dispatch, PBMs are profiting from clawbacks associated with the prescription drug purchases of more than 3 million poor and disabled Ohioans, despite laws intended to prevent the practice.
PBMs are supposed to reduce spending and increase access to medications. But stories like these seem to suggest the opposite.
Enter the clawback.
PBMs are responsible for setting your copay at the pharmacy — let’s say $10. And perhaps, in an attempt to make some money, they hypothetically set that copay much higher than the cost of the actual medication. Let’s say they set it to $50. They – hypothetically – might then be able to “claw back” the difference and make more profit.
But surely, they wouldn’t do such a thing, right? When they’re supposed to reduce spending?! Oh, but they surely would, and they surely do.
In another hypothetical scenario, PBMs might charge your insurance company much more than the drug actually cost them, and “claw back” the difference. And if they can’t get it from insurers, they’ll take it from pharmacies.
That’s what brings us to Ohio, where PBMs are “clawing back” money from pharmacists after the state considers claims “closed.” This is despite the fact Ohio has tried to regulate the practice.
It seems a legal loophole in the rule’s language has allowed for the practice to continue, but according to the article, Medicaid Director Maureen Corcoran says that even if the laws are technically being followed, PBMs are violating the intent and spirit of the law. You think?!
It’s worth remembering, again, that the three biggest PBMs – which control more than three-quarters of the nation’s prescriptions – are owned by or aligned with three of the country’s biggest insurance companies.
Can you guess who?
CVS Health’s Caremark is owned by CVS…which also owns Aetna. Then there’s UnitedHealthcare, which owns OptumRx, and Cigna, which owns Express Scripts.
In other words, these PBMs are incredibly profitable for health insurers, as the money ladders up to the same group of companies making care harder to access for patients. In other words, insurance companies continue to have an outsized role in when, how, and where patients get their medications — and patients and government agencies pay the price.