The Employer's Guide Blog for Overseeing PBMs

The Definition of Oversee: to watch over and direct (an undertaking, a group of workers, etc.) in order to ensure a satisfactory outcome or performance.

How Self-Funded Employers Leave Employees Holding the Bag: The Copay Clawback Phenomenon:

The retail cost of Sprintec is $10.04 but OptumRx required the pharmacy to collect $50 from the patient. OptumRx contributed nothing for the drug but collected the additional $38.35 clawback from the pharmacy, almost four times the retail cost of Sprintec. An unnamed pharmacist provided the claim information
Watch this short video for a demonstration on how clawbacks work.

This billing practice is known as a “clawback” and you may have no idea it’s happening because pharmacists aren’t yet allowed in many states to tell you under a gag order in place that restricts pharmacists from telling patients they are being overcharged. These clawback monies are a contributing factor to significant overpayment for pharmacy benefits management services.

Clawback revenue also plays a big role in the unchecked service fees to non-fiduciary PBMs who rely on them to cover overhead. For self-insured employers, it’s all about the contract so if you enter into an agreement with a PBM that does not drive radical transparency you leave employees holding the bag.

[Download the Full White Paper]

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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