What is a clawback?

1. A PBM clawback occurs when an insurance company assigns expensive copays to a drug, a price that may be significantly higher than the actual value and acquisition cost of the medications
2. Clawbacks occur when your pharmacy submits a claim for a prescription drug, and you’re directed to collect a specific dollar amount for the copay. The amount will likely be excessive and unrelated to the acquisition cost of the drug
Example: For MedicationX, the patient was charged a $50 copay for the drug, and $38.35 was directed back to the insurance company’s pharmacy benefit manager. The pharmacy received $11.65.
3. Unfortunately, patients often don’t know the costs of their prescriptions, or that there are cheaper options available.
4. And, many pharmacies are contractually prohibited from letting patients know about less expensive options.
5. To make it even more confusing, pharmacists may not be aware of these fees at the time they dispense the drug.
6. The plan and PBM will claw back these amounts periodically throughout the year through reconciliations that can occur months after the drugs are dispensed.
7. This can result in patients paying more for the drug than they would have without insurance.