Sometimes, so-called “gag orders” are needed, such as in judicial matters in which suppression of facts from the public is crucial to ensure fairness in the proceedings.
But the invocation of a “gag clause” barring the release of information pertinent to a consumer’s health — physically and economically — should never be allowed. And so it is that we applaud the federal passage late last year of legislation to eliminate contractual stipulations that had prohibited pharmacists from informing people about the cost of drugs and, potentially, giving them options if insurance co-pays end up costing more than paying out-of-pocket.
It long has been an insidious, little-known, policy for a pharmacy benefits manager — a person who contracts with pharmacies on behalf of insurers or drug companies — to make commercial pharmacists sign an agreement vowing not to reveal cost-conscious options to consumers seeking prescription drugs.
Now, such practices have come to light and given pharmacists the freedom, without fear of benefits-manager retribution, to tell a customer that paying cash for a generic drug might be less expensive than forking over the insurance-mandated co-pay. Currently, the federal law applies only to commercial insurance plans, but Medicare plans will be phased in starting in 2020.
Anything that saves patients money without jeopardizing their health is a welcome law, especially considering the prohibitive cost of many prescription drugs for chronic and episodic conditions. But the practices of the “middle men,” the pharmacy benefits managers, need further scrutiny – and more reining in.
Today in Olympia, Senate Bill 5422 is expected to get its first hearing in the Senate Health & Long-Term Care Committee. This bipartisan piece of legislation would further erode the hegemonic sway pharmacy benefit managers hold over both pharmacists they contract with and the public.
It, too, would eliminate contractual “gag clauses” on the state level, but it also further limits pharmacy benefits managers by prohibiting them from penalizing pharmacists who sell drugs for the cheaper out-of-pocket cost rather than a pricier insurance co-pay. Moreover, it bans pharmacy benefits managers from providing financial incentives for pharmacies to push the higher-priced offerings and would require managers to submit periodic reports detailing the amount in rebates they receive from pharmaceutical companies, as well as state any conflict of interest they may have with manufacturers. Failure to comply would result in a $1,000-a-day fine for pharmacy benefits managers.
Similar legislation died in the state House last year, but with the Trump administration signing off on federal bills, the co-sponsors (six Democrats, two Republicans) believe passage this year is possible. Perhaps as important as reigning in rogue pharmacy benefits managers is simply getting word out that consumers have the right to ask pharmacists their payment options — and, if asked, pharmacists can freely discuss them.
One of the co-sponsors of last year’s state bill, Rep. Valdana Slatter (D-Bellevue), admitted in hearings that she, too, was unaware of the outsized power of pharmacy benefits managers. That’s noteworthy because Slatter had been a clinical pharmacist for the biotech firm Amgen and had served on the Washington Board of Pharmacy. In introducing her bill, Slatter said, “As a bio-medical researcher, I want patients to have access to the best, least-expensive, most innovative medicines, but it seems we also need to shed more light on a very opaque health-care system.”
One consumer who testified of such pharmaceutical opacity last year was a woman from Everett, Heidi Barrett, whose four children have psoriatic arthritis and are prescribed the pricy drug Remicade, an immunosuppressant. She said the co-pay for her youngest son’s prescription came to $650 a month — 10 percent of the $6,500 total cost. But she later found out that her insurance company paid less, $4,100, for the drug. “If that saving had been passed on to us, just for Remicade, our family would’ve saved $1,000 a month,” she told lawmakers.
Such tales are not unusual, said Jeff Rochon, CEO of the Washington State Pharmacy Association. Increasingly, he said, insurance co-pays exceed the cash price but, before now, pharmacists were contractually bound not to mention the cost disparity to consumers. Managers also have employed “clawback” provisions, in which they instruct a pharmacy to collect an elevated co-pay amount from a patient, and then they recoup the surplus amount from the pharmacy.
The current state Senate bill seeks to help consumers by making the process more transparent.
Now, it’s up to consumers to take the initiative and quiz their pharmacists about possible price disparities. Remember, pharmacists are not required to offer the information, so you need to ask. Don’t be intimidated by the white coat; pharmacists’ primary obligation is to you, the patient, not some shadowy pharmacy benefits manager.
• Members of the Yakima Herald-Republic editorial board are Bob Crider and Sam McManis