Zurik Report: Part 1

 
Copay or you-pay? Prescription drug clawbacks draw fire 
 
Written by: Lee Zurik, Chief Investigative Reporter
Contributor: Tom Wright, Investigative Producer
 
Watch the Video Report on Fox 8 Webpage
 

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.

Most people think having insurance reduces their prices – that's why they buy insurance.  But our probe has found that that's not happening in some cases. 

Valsartan HCTZ, a high blood pressure medication, costs $14.43.  But documentation shows the pharmacy benefit manager instructed the pharmacist to collect a $30 copay.  The PBM clawed back $15.57 from the pharmacy and the customer. So the company is paying nothing toward the prescription here. 

“Every time the patient comes in, they're making more money because the patients need their prescription,” our source says of the PBM's.

Further complicating matters, pharmacies are contractually barred from telling customers that a cheaper alternative exists.

But many pharmacists, who asked that we not reveal their identities, gave us dozens of examples. They include a $22 clawback on a nasal steroid, fluticasone; $7.85 for a diabetes treatment, invokamet; $12.39 for diazepam, a drug that treats anxiety, muscle spasms and seizures.

The PBM acts as a middle man between insurance companies and pharmacies. Pharmacists submit claims to the PBM and they tell the pharmacy how much to charge each patient.

“Whatever the insurance company/PBM tells us to charge as a copay, we have to charge the patient for that,” our source says.  “We cannot discount it, we cannot forgive it. Our computer calls their computer. They tell us charge the patient this much money.”

Our investigation has linked one major healthcare provider to this practice of clawing back money from their customers: United Healthcare, through its PBM, Optum. Documents provided by pharmacists show Optum claws back money for some prescriptions, though not all.  

“It's really not insurance, is it?” wonders Randal Johnson, president and CEO of the Louisiana Independent Pharmacies Association. “I mean, what is that if you go in and they're negotiating a price for you, and it's actually costing you more to acquire the drug with your insurance than you could if you walked in off the street and you didn't have insurance?”

Last Monday, we requested an interview with Optum. The company asked us for documentation, which we sent.  Last Wednesday a representative emailed us, “Let me look it over and I will get back to you.”  But we never heard back.

Pharmacists also gave us documents that show clawbacks for Advantage Health Care, Innoviant and Cigna.

Cigna sent a very short response to our request for comment:

Cigna negotiates and contracts to create varied retail pharmacy networks to provide choice and value for our clients and customers.  We believe the negotiated rates with network pharmacies are fair and competitive and provide a range of affordable benefit plan choices.

Documents show Humana may be clawing back money from customers, too, when the customers' drugs aren't covered under the Medicare Part D program. Humana says it's not true, writing that they do "not engage in the practice you've described."

Humana may be saying that because, technically, they are not responsible for a copay since the drugs are not covered under the plan. But several pharmacists told us the documentation clearly shows Humana ordered the collection of copays that were higher than the costs of the drugs.

State Insurance Commissioner Jim Donelon says he wants to find out if this practice is legal. The insurance company is not paying anything toward the cost of the drug so, Donelon says, the copay could be an additional fee.

“It is an additional premium in my judgment, comparable to raising rates,” Donelon warns. “And I think that charge constitutes a price of having insurance with whatever carrier you're insured with.”

Under the Affordable Care Act, no one may be charged more for having a pre-existing condition.

Consider a hypothetical scenario in which two patients pay the same premium for their health coverage.  One needs a drug for high blood pressure; the other is healthy and doesn't need it.  If the person who needs the medication ends up paying a clawback, they could be paying more for the same coverage – that would, in a sense, be a penalty for having a pre-existing condition. 

And such a penalty would be illegal.

“I think you raise a very legitimate legal question because the Affordable Care Act did eliminate any discrimination based on health conditions, pre-existing conditions,” Donelon confirms. “So to charge a higher fee for a drug that is used by folks with greater health issues, more expensive treatment, I think can be validly argued as violative of the Affordable Care Act.”

You could say that, if the customer is paying more than the drug is worth, it's not a copay -  it's a “you-pay”.

“There's no copay,” our pharmacist says, “that is an absolute, additional premium being paid, that they're paying, that they don't realize.”

It doesn't take an "A" student like Isa Zorrilla very long to figure out the definition of a “you-pay”.

“That's wrong,” she says.

It's wrong because the companies don't tell customers about any "you-pay" – they still call it a copay.

“Again, the definition did say that they were going to pay some of it and the person wasn't going to be buying everything,” Isa notes.

Here's another example, and an expensive one, of a person buying everything and still paying a little more: Alcortin A, an anti-infective gel costing $3,708.81 per tube.  Documentation shows a customer paid a $3,713 copay.  In this case, the PBM clawed back $5 – yet another case of some insurance companies' definition of “copay” not passing muster.

“Isn't insurance you pay for it and they help you back?” our 11-year-old analyst tells us.  “So basically you're just paying them for nothing.”

Again, if you're a customer of any of these health insurance companies, clawbacks do not occur on every medication. Nonetheless, and regardless of your insurer, it's probably a good idea to ask what the cost of your medication would be without insurance - every time you go to the pharmacy.