Commercial Claims Reimbursed through Embedded GoodRx® Discount Cards

Pharmacies have been reaching out to PAAS National® with concerns about claims being reimbursed through an embedded discount card (e.g., GoodRx®) rather than a patient’s commercial insurance plan benefit. Most concerning is that these claims have negative remittances or “clawback fees” that reduce pharmacy revenue and may pose problems when trying to perform a Coordination of Benefits (COB) claim to a secondary payer, such as Medicaid.

PAAS wrote about Discount/Cash Cards being disruptors in the industry last March, after speaking at NCPA’s Multiple Locations Conference. The crux of the issue is discount cards have been gaining popularity (no thanks to GoodRx®) and have been effective at undermining the perceived benefit that PBMs are supposed to provide (i.e., why is GoodRx® able to offer a better price on my prescriptions than my insurance?). Consequently, major PBMs have embedded these discount card networks into the plan benefit design, which allows patient pay amounts to count towards deductibles (see press releases as follows).

While a pharmacy may have chosen to decline processing claims for GoodRx®, these newly embedded plans are not as easily identifiable (particularly in advance), and when they are, pharmacies can find themselves in a precarious situation. Contractually, pharmacies should not …

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reverse the claim and bill as cash for the same amount. This can impact performance networks and adherence scores (impacting a pharmacy’s ‘performance incentives’). Additionally, it can jeopardize a pharmacy’s Usual and Customary pricing. Patients also won’t get the benefit of it applying towards their deductible, and if they submit the receipt to the PBM, it will likely come back to the pharmacy with a PBM inquiry into pharmacy operations.

In some instances, we have seen Caremark claims provide an adjudication message notifying [the pharmacy] that the claim processed via a discount card and that the patient may ‘opt out’ if their claim needs to be processed as a COB. If Medicaid is a secondary payor, patients would need to ‘opt out’ of the Cost Saver option and then the pharmacy would be able to reverse and reprocess claims through the commercial benefit (not the discount card) to allow appropriate COB processing.

While PAAS strongly opposes this novel PBM tactic to gouge network pharmacies, it’s important to be aware of downstream effects if drastic measures are taken. PBMs can easily identify pharmacies that are quickly reversing claims processed under discount networks.

Here is a video explaining the workflow of these discount card claims and how the money is suspected to flow.

PAAS Tips:

  • Reversing and “cashing out” claims paid through discount cards may:
    • Prevent patient pay amounts from counting towards deductibles
    • Violate Usual & Customary pricing
    • Jeopardize network/contract status
  • Stay engaged politically, both at your state association and federally through NCPA
    • There’s a belief that these discount networks may violate antitrust laws through pricing fixing and we need political advocacy to shine a light
      • Discount networks create data and pricing information to be shared almost ubiquitously
      • Consider the corollary from the FTC: Price Fixing by Algorithm is Still Price Fixing

Eric Hartkopf, PharmD