The term clawback, when used in pharmacy, refers to an adjudicated claim for a medication that includes an extra fee to be paid by the patient above and beyond the cost of the medication. In the most basic form, a clawback looks a little like the following:
- Pharmacy Allowed Payment: $10.00
- Total Patient responsibility: $15.00
In this simple example, the pharmacy will collect $15 from the patient. The payor will then collect $5 from the pharmacy. If this seems complicated, it is. A local television station in New Orleans (WVUE, FOX 8) recently released an investigative piece on the practice Copay or you-pay? Prescription drug clawbacks draw fire. The information in both the video and the text do a good job of explaining this complicated topic. Follow the link to review the materials.
One assertion made by the report, in the Thriving Pharmacist’s opinion, is not completely accurate and merits additional clarification. This has to do with a pharmacy’s cash price potentially being lower than the clawback price. This is never true; a pharmacy must charge the same usual and customary price for cash customers as they submitted to the insurance. This means that the cash price will necessarily be higher than the adjudicated claim plus the clawback. That being said, it does not mean that there are not other discount programs available that could make the same drug potentially less than the clawback price. It always pays to ask, and in my experience, pharmacists generally don’t like clawbacks. If there is another way to help the patient pay less, they will tell you about it.
