Truveris has noticed a trend in the market regarding zero-balance claims. Also called zero-balance due (“ZBD”) claims, these are situations where the prescription price is less than the participant’s copayment. For example, say you get a prescription for amoxicillin 250mg for a simple infection. The 30 capsules would be paid at a MAC price of about $0.20 per capsule, or about $6.00 total. Your Plan’s copayment for a generic drug is $10.00. Since the cost of your prescription is less than the copayment, you pay the $6.00 and go home.
Or do you?
In many cases, PBMs have convinced Health Plan sponsors to have participants pay either the full copayment or the pharmacy’s cash price (also called the Usual and Customary, or U&C, price), whichever is less, for ZBD claims. In the example above, let’s say the pharmacy’s cash price for 30 amoxicillin capsules is $11.99. You would end up paying your full copayment of $10.00, since the contracted price ($6.00) is less than the copayment, and the copayment is less than the U&C price. You end up paying $4.00 more than your Plan would have paid for the same prescription.
And where do the extra dollars go? To the pharmacy, who presumably give better overall discounts to the PBMs because they get to keep the extra on ZBD claims. In fact, Truveris has not noticed any improvement in discounts because of ZBD claims. We believe it is simply a way to have Plan participants pay more for prescriptions and take some financial liability away from the Plans.
It is possible that Health Plans can maintain or reduce increases in participants’ premiums by using this copayment logic for ZBD claims. However, Truveris suspects that it is simply a way for PBMs to give incentives to their retail pharmacy networks in order to keep them in the fold. We encourage Health Plans to ask their PBMs about ZBD claims and ensure their participants are not being overcharged.