Getting a prescription filled at your local drugstore could be cheaper under a federal law passed in late 2018.
The new legislation that was passed in October 2018 bans gag clauses used in pharmacy contracts with insurers in more than a dozen states. The clauses prevented pharmacists from telling customers when they could save money by paying out of pocket instead of using their insurance.
The new rules have a catch, however. Pharmacists won’t be required to tell patients about the lower cost option. If they don’t, it’s up to the customer to ask.
The gag clauses are now banned for private insurance. They’ll take effect in Medicare Advantage and Part D prescription drug plans on Jan. 1, 2020. At least 29 states have passed laws to ban the gag clauses.
Without the gag rules, pharmacists will be able to talk honestly and candidly about drugs and costs. For example, a consumer with a large co-pay may pay less by buying the drug themselves and not using their insurance. A pharmacist can now tell them about this option.
But for Medicare Advantage or Part D patients, they’ll still be restricted on what discounts they can access, regardless of if a gag clause exists, until the new law takes effect in 2020.
People with Medicare Part D drug insurance overpaid for prescriptions by $135 million in 2013, according to research published in The Journal of the American Medical Association (JAMA) in March 2018. Co-payments in those plans were higher than the cash price for nearly one-in-four drugs purchased in 2013. For 12 of the 20 most commonly prescribed drugs, patients overpaid by more than 33 percent.
Federal law prohibits drug companies from giving coupons or discounts to people who get their health benefits through the federal government because it’s considered a violation of the government’s anti-kickback statute.
Medicare patients don’t have to wait until 2020, however, for the gag order ban to take effect. The Medicare rule allows a pharmacist to answer questions about lower price options if a customer asks.
Medicare patients looking to cut costs should ask their pharmacist if a generic or lower-cost drug is available, then figure out if paying out of pocket or using a discount card would be less expensive than the insurance co-pay.
