As a part of President Donald Trump's blueprint to bring down prescription costs, Medicare officials have warned insurers that “gag orders” keeping pharmacists from alerting seniors that they could save money if you are paying cash – instead of using their insurance – are “unacceptable and contrary” towards the government's effort to advertise price transparency.
But the company stopped lacking requiring insurers to lift such restrictions on pharmacists.
That does not mean individuals with Medicare drug coverage are destined to overpay for prescriptions. Under a little-known Medicare rule, they are able to pay a lesser cash price for prescriptions rather than utilizing their insurance. However, they must ask the pharmacist about this option, said Julie Carter, federal policy associate in the Medicare Rights Center, a patient advocacy group.
“When they bring it up, only then do we can tell them of those prices,” said Nick Newman, a pharmacist and the manager at Essentra Pharmacy in rural Marengo, Ohio. “It’s a moral dilemma for the pharmacist, knowing what might be best for that patient but not having the ability to help them and hoping they will ask you concerning the comparison.”
A simple question could unlock some savings for countless beneficiaries.
But details may be hard to locate: Medicare’s website and annual handbook don’t bring it up.
“If you don’t know that there are a couple of different prices that may be available at a pharmacy, you don’t understand what you don’t know,” said Leigh Purvis, the AARP Public Policy Institute’s director of health services research.
Researchers analyzing 9.5 million Part D prescription claims reported inside a letter within the Journal of the Ama in March that a patient’s copayment was greater than the cash price for nearly One in 4 drugs bought in 2021. For 12 from the 20 most commonly prescribed drugs, patients overpaid by a lot more than 33 percent.
Although the research found that the typical overpayment for any single prescription was relatively small, Newman said he had seen consumers pay around $30 a lot more than the money price.
And many beneficiaries may not realize that when they pay a lower cash price for a covered drug at a pharmacy that participates in their insurance policy and then submit the correct documentation, insurers must count it toward their out-of-pocket expenses. The total of these expenses can trigger the drug coverage gap, commonly called the doughnut hole. (This season, the gap begins following the plan and beneficiary spend $3,750 and ends once the beneficiary has spent a total of $5,000.)
Daniel Nam, executive director of federal programs at America’s Medical health insurance Plans, a trade group, agreed that “patients should have access to the lowest price possible in the pharmacy.” But he explained Medicare’s warning, contained in instructions this month, takes are designed for an ever more rare occurrence. Gag order clauses are “not something they are incorporating to their contracts,” he explained.
UnitedHealthcare, whose popular prescription drug plans dominate the market, doesn't include them in almost any of its Medicare, Medicaid or commercial insurance contracts, said Matt Burns, a business spokesman.
Pharmacy benefit managers also said gag orders are not typical. “If it's happening, it is very much an outlier,” said Mark Merritt, president and CEO of the Pharmaceutical Care Management Association.
However, some pharmacists disagree. Kala Shankle, policy and regulatory affairs director for that National Community Pharmacists Association, which represents 22,000 independent pharmacies, said insurers have punished pharmacists who violate gag orders by dropping them in the plan’s network.
In Ohio, one of many states that have banned gag orders in insurance contracts, including some Medicare drug plans, officials responded to complaints concerning the problem.
“The Department has gotten inquiries related to entities withholding cost-saving information from consumers, which sometimes results in an insured [patient] paying more for pharmacy benefits than the actual price of such pharmacy benefits,” the department said last month.
Illinois and Pitt legislators are considering bills to make such restrictions illegal, and similar legislation continues to be introduced within the U.S. Senate.
“When we didn’t have these gag clauses, there would 't be a need for the legislation and policy changes movement that’s going on in the country,” said Garth Reynolds, executive director of the Illinois Pharmacists Association.