Zurik: Pharmacists, customers nationwide coping with clawbacks

NEW ORLEANS (WVUE) - More than 80 million people in the U.S., many right here in Louisiana, are impacted by the focus of our Medical Waste investigation. And if you pay for United or Cigna health insurance, you're in that number.

But even if you're not, you could be overpaying for your medication.

"I do my best, actually, just to provide for me and my son," says Nicole, single mother of a seven-year-old boy. "He's really smart, very intelligent. He's been reading since he was two.  He's great with his classmates. All of his teachers love him. He's in Cub Scouts."

Nicole even gets a little embarrassed when it sounds like she's bragging. "He's just a great kid, I kid you not!" she tells us. "I'm not just saying it because he's mine."

Nicole's son has a rare medical condition. "From the information from the ophthalmologist, it's an allergic conjunctivitis that's more rare, and found mostly in African-American males, young African-American males," she explains.

Nicole took her son to the doctor, who prescribed an eye drop – a medication that cost $473.

She says she simply cannot afford that. "And as a single parent I felt that I was failing," she says, "not being able to provide the healthcare that he deserves."

After seeing our Medical Waste investigation, Nicole started doing some research.  It turns out her insurance company may be overcharging her for the prescription, clawing back money.

"I feel like I have options now," Nicole tells us, "as a consumer but more than anything as a parent. "

She found the drug much cheaper by paying for it without her insurance. "I have found it actually at half-off," she says.

Our investigation revealed the nation's largest insurance carrier, United HealthCare, makes customers pay a premium on some prescription drugs, charging them more than the actual cost – clawing back money from the pharmacy and customer.

"You're naturally assuming that your insurance is paying for part of the cost of the medication," notes Doug Hoey, CEO of the National Community Pharmacists Association, a trade group that represents independent pharmacies,

Pharmacy benefit management firms actually dictate these clawbacks.  Documents provided by multiple pharmacists show the PBM for United HealthCare, OptumRx, frequently overcharges for medication. Some pharmacists think the practice is most common with generic drugs and high deductible insurance plans.

"Most consumers don't know that you've got these middlemen called PBM's, like Optum or Catamaran, in the middle of the transaction," Hoey says. "And they manage hundreds of billions of dollars."

OptumRx, one of the largest PBM's, is actually owned by United HealthCare.

"The biggest PBM is bigger than Walt Disney, McDonalds and Ely Lilly combined," Hoey tells us. "Those three iconic companies together are not as big as the biggest PBM, Express Scripts - yet most consumers have no idea what Express Scripts is."

FOX 8 viewers have sent dozens of examples of potential clawbacks by these PBM's.

One viewer sent us two medications - one for blood pressure, the other high cholesterol.  In both, United HealthCare charged him a $10 copay for a 30-day supply.  But the drug's actually cheaper off insurance, which this viewer found out when he went to an independent pharmacy. He bought a 90-day supply without insurance, saving $10 on one prescription and $15 on the other.

Our investigation has found United and another insurer, Cigna, frequently claw back money.

A Cigna customer in Kenner sent us a receipt that shows what could be another example of a clawback.  The high cholesterol medication costs about $20 through Cigna.  After our stories, this customer did some searching and found he could save about $9 by buying the med without insurance.

"There are clawback issues hitting pharmacists in every state," Hoey warns.

We've heard from pharmacists all over the country telling similar stories.  For instance, a pharmacist in the southeast U.S. sent us a spreadsheet of clawbacks. It includes a $69 clawback for a high blood pressure drug, $50 for oxycodone, $44 for an ADHD medication.

For that high blood pressure drug, the PBM made the customer pay a copay of $76.89. The pharmacy kept $7.47 and the PBM clawed back $69.42 from the pharmacy and customer.

A pharmacist in the northeast U.S. sent us a clawback from last Friday: OptumRx charged a $270 copay for a nausea drug.  OptumRx paid the pharmacy $3 for the cost of the medication and a $1.50 fee, and clawed back $265. The pharmacist says, without insurance, the customer could have bought the medicine for $15.

And another pharmacist sent us a prescription bought in the Medicare Part D program that may reveal another company clawing back money.  Aetna made the customer in this case pay a $50 copay – but the pharmacist says he would could have sold it to the same customer without insurance for about $17.

A quick search on the computer shows that drug is used to treat depression - Aetna charged a customer battling depression $50 for something that costs $17 without insurance.

"From an ethical standpoint, it sure feels unethical," Hoey says.  "And as a pharmacist wanting the patient to be healthy and get the best value for their medication, everything about it feels wrong."

In a statement last week, OptumRx admitted to the clawback, calling it part of their "Pharmacy Reimbursement Overpayment program."

"I've been in the business 25 years as a pharmacist and 35 years, you know, working for my family's pharmacy," Hoey says.  "And I thought I'd seen everything in my career, until I saw that statement. And then, I couldn't believe it. I was stunned, I was shocked that they would actually admit to calling it an overpayment program for consumers."

One FOX 8 viewer, Tana, told us by email that she researched her thyroid medication after watching our report.  United charges her a $35 copay - she now knows she can save about $15 a month, buying it without insurance.

"It feels like a complete disservice," Nicole says after hearing our findings.

Before our interview, Nicole reached out to us on Facebook.  The first three letters she typed - "OMG" – were her first reaction to some health insurers overcharging for medication.

"It's not like I'm buying a car," she says. "This is my son's life, this is his health, this is his well-being.  It almost feels like these drug companies are using… are taking advantage of folks. They're taking advantage."

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