Researchers analyzing 9.5 million Part D prescription claims reported in a letter in the Journal of the American Medical Association in March that a patient’s copayment was 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%.
Although the study found that the average overpayment for a single prescription was relatively small, Dr. Newman said he had seen consumers pay as much as $30 more than the cash price.
And many beneficiaries may not know that, if they pay a lower cash price for a covered drug at a pharmacy that participates in their insurance plan and then submit the proper documentation, insurers must count it toward their out-of-pocket expenses. The total of those expenses can trigger the drug coverage gap, commonly called the doughnut hole. (This year, the gap begins after the plan and beneficiary spend $3,750 and ends once the beneficiary has spent a total of $5,000.)
Daniel Nam, executive director of federal programs at America’s Health Insurance Plans, a trade group, agreed that “patients should have access to the lowest price possible at the pharmacy.” But he said Medicare’s warning, contained in a letter in May 2018, takes aim at an increasingly rare occurrence. Gag order clauses are “not something they are incorporating into their contracts,” he said.