| A claim to claim comparison is possible because of the level of recordkeeping in the pharmacy benefit. Each RX claim has a record of the total cost of the prescription to the plan before the member co-payment. Additionally, the date of the prescription, the drug’s “bar code” (the National Drug Code), the drug name strength and quantity dispensed is recorded as well. Some medications on the market come in “fractionally-sized” unit-of-use. This means that certain products are not available in a “round” number metric quantity, but rather in quantities such as 2.5ml. When these fractional quantities are processed by some PBM’s the plan sponsor could potentially be charged the “rounded up” whole number quantity, such as 3ml for the 2.5ml size. When “rounding up” occurs, the plan is charged for 0.5ml (3.0-2.5) to much for the drug. The zero balance co-payment occurs when the pharmacy benefit manager (PBM) may allow for an artificial elevation in the cost of inexpensive drugs. This typically occurs with generic drug products. The plan cost is “0” (zero) and the member co-payment becomes the plan summary recorded co-payment but not the PBM “allowable” based upon MAC pricing. | |
