Prescriptions may be cheaper without insurance

Gag clauses prevent pharmacists from telling you
Posted at 3:17 PM, Dec 19, 2017
and last updated 2017-12-19 23:26:04-05

KANSAS CITY, Mo. – Countless people could be spending more money at the pharmacy than necessary.

Most people assume their insurance saves them money on prescription drugs, but the 41 Action News Investigators found that isn't always the case, and your pharmacist isn't going to tell you there's a cheaper option.

In Kansas and Missouri, pharmacists are placed under gag clauses that prevent them from telling a customer that their prescription drug could be cheaper if rang up without insurance.

Drug benefit managers

Middlemen, known as drug benefit managers (PBMs), negotiate prices between drug companies and insurance providers. While the intention is to get the insurance company the lowest price on a drug, often times it ends up costing the consumer more. 

Steve Hoffart, a pharmacist from Texas, told NBC News it's a common occurrence for a customer to pay more than they should.

"It's extremely hard to see a patient pay more for a drug than what they should be," Hoffart said.

For example, Hoffart sells Simvastatin, a common cholesterol medication for $18.59. However, most of his customers pay $42.02 because of their copay: a $24 difference. 

Hoffart said he can't tell his clients there's a cheaper way because of the gag clause he and other pharmacists are placed under by PBMs.

"It's in the contract language," Hoffart said. "We cannot divulge that information."

Who benefits from the excess money?

The excess money winds up in the pockets of the PBMs in what's known as a clawback. 

For example, if a prescription costs $20, $5 might go to the drug company, another $5 might go to the pharmacy and the remaining $10 could be taken by the PBM.

Nation reacts to clawbacks and gag clauses

Seven states have outlawed clawbacks and or gag clauses.

While Kansas and Missouri are not included in those states, legislation has been introduced in Missouri to put an end to both practices.

In the meantime, the only way to know if paying without using insurance is the cheaper option is to ask. That unlocks the gag clause. 

Getting the best deal by comparison shopping

Aside from getting around the gag clause to save money, for those who want to know which pharmacy sells a particular drug at the best rate, websites like allow customers to compare prices.

For example, a 90-day supply of Lipitor is just $13.00 at Albertsons. Most other pharmacies including Right-Aid, Target (CVS), and Walmart sell the same prescription for about $20. Walgreens sells it for about $30 more at $42.75.