06/18/2026
These are three fills of the same prescription that our pharmacy processed in May and June (to start, we only filled seven tablets to line it up with the patient’s other prescriptions). Focusing on the two most recent fills, this is:
-The same patient
-The same medication
-The same quantity
-The same insurance plan!
Only two things changed between May and June:
1) The patient’s deductible period started over in June, making him responsible for 100% of medication costs. He had previously met his deductible, so all prescriptions filled in May were at no cost to him.
2) The insurance plan increased the total cost of this prescription from $0.51 to $1,163.18. That’s an increase from less than $0.02 per tablet to $38.77 per tablet!!!!
The wholesale cost of this medication has not changed over the last month. There is no shortage of this medication that might change the market price.
The only thing that changed was who was paying the bill. When the insurance company was responsible for paying for the medication, our pharmacy was grossly underpaid. When the patient was responsible, he was grossly overcharged.
Let’s explore several reasons that this insurance company would do this.
1) Spread Pricing: prescription insurance companies act as middlemen, paying pharmacies for prescriptions and then simultaneously billing someone else (usually a health plan or an employer) for the medication. This final bill is often marked up from what the pharmacy was paid, and the difference is called the “spread”. While our pharmacy was only paid $0.51 for the prescription on 5/16, you can be sure that this prescription insurance company charged more than this. The total amount could have been $5. It could have been $1,000. No one knows because these insurance companies don’t share these types of data.
2) Steering: this prescription insurance company also owns pharmacies, and the act of driving patients to their own pharmacies is called “steering”. Steering can take several forms. Patients can be told that their medication is only covered at an insurance-owned pharmacy. Patients can also be told that their copays are substantially lower at an insurance-owned pharmacy. In a scenario like this, we wouldn’t be surprised if this patient received a letter or phone call from their insurance plan, letting them know that they could get a lower price at a different pharmacy...one that the insurance company owns.
3) Different Payments for Different Pharmacies: prescription insurance companies routinely pay their own pharmacies at higher rates. Several government agencies have been investigating this, and occasionally paying an independent pharmacy like ours at a high rate gives them data that they can “cherry pick” to attempt to prove that they pay all pharmacies fairly.
4) Clawbacks and Audits: there are several methods that prescription insurance companies can utilize to pull back money from the pharmacy AFTER a prescription is filled…even if the patient is the one footing the bill. The insurance company can claim our pharmacy was overpaid and pull back money. The insurance company can also attempt to audit this prescription, and if they find even the tiniest clerical error, they will pull back the entire cost of the prescription. And the patient would not get a refund.
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Here’s the most important part of this post:
A new Kansas law is set to go into effect on 7/1/26 that regulates these prescription insurance companies, who are technically called Pharmacy Benefit Managers. Starting in July, spread pricing will be illegal. Insurance clawbacks from pharmacies will be illegal. Paying an insurance-owned pharmacy at a higher rate will be illegal.
But this law will only be effective if it’s actually enforced.
The Kansas Department of Insurance will be in charge of regulating Pharmacy Benefit Managers under this new law. Our state is set to elect a new Kansas Insurance Commissioner in November, and this is one of the most important votes in the upcoming election.
One of the candidates for Insurance Commissioner is heavily funded by the insurance industry. He has received campaign contributions from insurance companies, Pharmacy Benefit Managers, and the lobbying group that represents the largest Pharmacy Benefit Managers who have been crippling pharmacies for decades. Not only did this candidate vote against this bill to regulate Pharmacy Benefit Managers, but he also attempted to sabotage the bill in every way that he could. Kansas pharmacists are truly afraid that he will refuse to enforce this law if he is elected as Kansas Insurance Commissioner.
The November election is closer than you think, and we need to start spreading the word that Senator Dinah Sykes needs to be elected as our next Kansas Insurance Commissioner. Please share this post and help us spread the word. We need to keep these giant insurance companies from playing games with the health of the citizens of Kansas.
