HHS finalizes rules to nix Part D rebate safe harbor, tie Part B prices to foreign countries11/20/2020 Fierce Healthcare
The Trump administration finalized a rule Friday that gets rid of the safe harbor shielding Medicare Part D rebates from the anti-kickback statute and a rule that will tie certain Medicare Part B drug prices to those paid by countries overseas. Trump called for both rules to be published during a flurry of executive orders back in September. The rebate rule is expected to generate significant pushback from providers, payers and pharmacy benefit managers (PBM) that say it will harmfully impact seniors' access to cheaper drugs. The so-called most-favored-nation rule will also change how providers get paid for administering and storing Part B drugs. The rebate rule will replace the safe harbor for Part D rebates, meaning they could be targeted under the federal anti-kickback law, with a new safe harbor that applies only to discounts offered at the point of sale. The goal is to curb the use of rebates in Medicare Part D, which Health and Human Services Secretary Alex Azar has described as a "kickback" that drug companies must give to pharmacy benefit managers and insurers in order to get on their plan formularies. HHS put out a proposed rebate rule in 2018 and it generated intense pushback from the insurer and PBM industry. The industries complained the rule will raise premiums for Part D seniors, pointing to a report from the Centers for Medicare & Medicaid Services' actuaries that the rule would lead to a 19% hike in premiums. A report commissioned by the PBM industry group Pharmaceutical Care Management Association said that the rule would also hike federal spending and is unlikely to lower prices. Payers and PBMs are worried that the rule would remove a key negotiating tool that they have with drug companies to ensure lower prices. In turn, the pharmaceutical industry has been a major proponent of the rule. Rebates have generated PBMs and insurers a lot of money. A 2018 analysis from the consulting firm Altarum found that insurers got $89 billion in rebates from drug companies in 2016. The threat of premium hikes to seniors was a major reason the White House scuttled the rule last year and its revival is a boost for Azar, who has complained that PBMs don't pass on the savings from rebates to beneficiaries. Continue Reading
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Deborah Keaveny owns and operates pharmacies in Winsted and Cokato, and was featured in a Nov. 1 article in the Star Tribune. She is also responsible for starting a Google group called MNlndys - Minnesota Independent Pharmacies, which currently has more than 100 independent pharmacy members. "We needed a way to be able to talk about what is working in stores and what is not," she said. "Independent pharmacy has hit a point where we really are fighting to survive, and fighting together is much better than fighting alone." Going Up Against Giants Independent pharmacies have been wrestling with Pharmacy Benefit Managers, or PBMs, to keep their customers for several years. Continue Reading ABC7 Talk Business & Politics
An audit performed for the Arkansas Insurance Department of the state’s three dominant pharmacy benefit managers found different-sized pharmacies were paid different amounts for the same drugs last year, though in most arrangements it wasn’t considered significant, and that at least two of the PBMs charged pharmacies “clawback” fees. But one PBM, CVS Caremark, says differential payments are normal, and it objects to the audit’s reliance on only one contract to make a determination about those clawback fees, which were legal at the time. The limited scope examination was conducted of the PBMs serving the state’s Arkansas Works and Provider-led Arkansas Shared Savings Entity (PASSE) health plans. PBMs serve as middlemen between insurers and pharmacies. The PBMs audited were CVS Caremark, Optum RX and Express Scripts. CVS Caremark provided PBM services for Arkansas Blue Cross and Blue Shield, Centene and the Empower PASSE. CVS Caremark accounted for 85.16% of the Arkansas Works claims examined. OptumRX was the PBM for Qualchoice. Express Scripts was the PBM for the Summit Community Care PASSE. The audit covered Jan. 20 to June 30, 2019. The firm, Lewis & Ellis of Allen, Texas, used data only from March 2019 and extrapolated the findings for the rest of the period. The examination was completed on July 27, 2020, and posted Oct. 28. The audit focused on spread pricing, which occurs when a PBM pays pharmacies less than it was paid by the insurer and pockets the difference. The practice was made illegal by a 2019 law. It also covered two other practices: differential payments where pharmacies are paid different amounts for the same drugs, and direct and indirect renumeration fees, or clawback fees, which are retroactive fees assessed on pharmacists after drugs are dispensed. The examiner found CVS Caremark and OptumRX had no significant spread pricing. However, it found that more than 83% of claims administered by Express Scripts through the Summit Community Care PASSE showed spread pricing practices. That amounted to more than an 18% difference between what Express Scripts charged the health plan and what it paid the pharmacy. In its rebuttal, Express Scripts objected to the examiner’s definition of “spread pricing.” It said the auditors calculated spread incorrectly, and it objected to the audit report extrapolating from only one month’s data. Continue Reading Smerconish
There's an old French proverb, "the more things change, the more they stay the same." Nothing could be truer of the U.S. healthcare system, especially in the shell game of prescription drug pricing. Although the cost and accessibility of healthcare – particularly medication – has hovered among voters' top concerns in presidential and midterm elections since at least 2012, elected officials have little power to control, let alone keep their campaign promises to lower drug prices. It's counterintuitive to think those who can create, execute, and enforce the laws somehow lack the power to rein in the drug industry. But it's not "Big Pharma" who's the problem, it's "Big Health Insurance." It doesn't get any bigger than CVS Health, UnitedHealth/OptumRx, and CIGNA/Express Scripts. These three behemoths – publicly-traded corporations and their pharmacy benefit manager (PBM) divisions – hold an estimated 74% of the market share for prescription drug benefits. They are the true arbiters of drug prices. You may have heard the term "PBM middlemen" (or just "middlemen"). Most people don't know PBMs, but they see the carrier logo emblazoned on their prescription drug coverage card. That carrier is the PBM. PBMs began by processing pharmacy claims in the late 1970s-early 1980s, but have grown to a nearly $400 billion industry. They are the designers of benefit plans, gatekeepers of patient plan formularies, the approvers of prior authorizations, and the enforcers of "step" or "fail first" therapies. Though they are drug price negotiators, they are not negotiating on anyone's behalf but their own. They "negotiate" by requiring drug manufacturers to pay "rebates" – you and I would call them "kickbacks" – for drug placement on the patient's plan formulary of approved drugs. The more expensive the rebate/kickback, the better or more exclusive the drug's placement. This is why some patients are required to buy brand medicines instead of less-expensive generics. The PBM makes more every time that brand is dispensed. The travesty of these "negotiated" prices is the end payers - often the patient's employer - and the patient see almost none of these savings. If PBMs' alleged competitive edge is their so-called ability to negotiate better prices, their secret revenue gain comes from the difference between the price they charge the plan and the amount they reimburse the pharmacy. Several studies of different states' Medicaid programs have shown taxpayers footing the bill for anywhere between $224 and $300 million in spread – the profit pocketed by PBMs. The first study in Ohio found the average spread was more than $6 per prescription, meaning the State of Ohio paid an average additional $6 per prescription per Medicaid enrollee per month. And that's just one state – 49 others are dealing with some version of spread pricing and rebate kickbacks to PBMs. And that's just on the "normal" prescriptions. The news is far worse for more expensive "specialty" medications, where studies are finding PBMs steer patients to PBM-owned pharmacies and mail order. Self-dealing and patient steering are revenue generation schemes straight out of the PBM playbook. Still, their unfortunate consequences leave patients scrambling as "pharmacy deserts" emerge in the wake of independent and community pharmacies' closures. No business can withstand for long having its customers routed to the competitor. Continue Reading Healio
The American College of Rheumatology and 11 other provider and patient groups have called on UnitedHealthcare to cancel its proposed copay accumulator initiative, arguing it would increase financial burdens and limit access to treatments. According to the group, United Healthcare will as of Jan. 1 require providers to report the amount their patients receive in copay assistance for office-administered treatments. The insurer will then use this information to enforce a copay accumulator, which would prevent funds from assistance programs from being applied to patients’ annual deductible and out-of-pocket maximums, the ACR said in a press release. The ACR and 11 other provider and patient groups have called on UnitedHealthcare to cancel its proposed copay accumulator initiative, arguing it would increase financial burdens and limit access to treatments. Source: Adobe Stock“Rheumatologists treat many patients with chronic conditions like rheumatoid arthritis and lupus that sometimes require using complex biologics to avoid debilitating pain, disability or life-threating complications,” Chris Phillips, MD, chair of the ACR Insurance Subcommittee, said in the release. “Unfortunately, biologics are expensive, and for the past few years, insurers have been moving them into ‘specialty tiers’ that require patients to pay a percentage of the actual cost of the drugs.” “Copay assistance programs thereby preserve patient access to otherwise unaffordable drugs when out-of-pocket expenses are high,” he added. “The dramatic increase in out-of-pocket expenses will put these treatments out of reach for many patients, potentially leading to disease flares, expensive surgeries, permanent disability and higher overall health care costs.” According to the ACR, the annual price for biologic therapies ranges from $22,000 to $44,000, with patients on specialty tiers having to pay hundreds or thousands of dollars in copayments each month, or otherwise going without treatment. If copay assistance funds are no longer counted toward deductible and out-of-pocket maximum requirements, the ACR argued, patients will be forced to pay these additional costs. “This is particularly concerning for rheumatology patients, because the medications they require are often single-source therapies with no equivalent generic product or therapeutic alternative that is cheaper,” read the ACR release. In addition, the groups said requiring physicians to report on the amount their patients receive in copay assistance forces them into an ethically objectionable position. “Reporting this information knowing that it would likely price a therapy out of reach for a patient who needs it to avoid flares and further disease progression is counter to our oath to first due no harm,” Phillips said in the release. “It would also strain the doctor-patient relationship and would be unethical under AMA guidelines. No one living with a chronic disease should have to choose between their physical and financial health.” The groups expressed these concerns to the insurer in a letter dated Oct. 7 to Lewis G. Sandy, MD, FACP, executive vice president of clinical advancement for UnitedHealth Group. Other than the ACR, the signatories include the AIDS Institute, the American Academy of Dermatology Association, the American Academy of Neurology, the American College of Gastroenterology, the American Gastroenterological Association, the American Kidney Fund, the Arthritis Foundation, the Association for Clinical Oncology, the Cancer Support Community, the Council of State Rheumatology Organizations and the National Multiple Sclerosis Society. A spokesperson for United Healthcare did not immediately respond to a request for comment. According to the ACR, at least four states have prohibited copay accumulators in individual and small group health plans, due to concerns of patients abandoning their prescriptions during the deductible phase. Salt Lake Tribune
I help people. That’s what I do. I’ve been a practicing nurse since 1986 and a nurse practitioner for the past 11 years. I’ve watched the health care profession entirely change when the coronavirus emerged. Suddenly, nurse practitioners like me are in the spotlight, on the front line, rather than quietly doing our jobs in the background. Many of the nurse practitioners I know would rather be doing our work one patient or family at a time, rather than in public. But, now that NPs are more visible, I have a few recommendations that I think could make a positive change for all of us. As a global positive change, know that every health care worker feels the stress of this moment with you. We see the statistics every day, the evidence of our patients' panic with every cough, and the arm’s-length distance that people keep between themselves and anybody wearing scrubs. Even in the difficulties of this year, we’re using our experience, education and personal approach to help people make it through their medical problems and their fears. We feel the weight of this. Each patient is an individual. Your nurse practitioner cares. We’ve all seen the landscape of health care change significantly. The bureaucracy. The paperwork. The insurance red tape. All the ever-changing mandates and regulations and loopholes that lead patients to view health care as a burden. We all feel the frustration rather than feeling, well, healthy. Which brings me to the local change. In my practice, I have come to dread the words “pharmacy benefit manager.” Pharmacy benefit managers work for health insurers. They insert themselves as intermediaries between patients and their care providers. The PBMs' job is to secure “rebates” on prescription drugs to get preferential treatment on the insurers' drug plans. But this also limits which medications will be paid for on your plan. For me, the decision on whether patients can use a particular prescription medication should be based on their personal health history and need. This can prevent more side effects and having to “try” multiple medications before we can use the right one. Unfortunately, the reality is that these PBMs keep a chunk of the rebate for themselves and the health care plans, rather than the full discount going to the patient who needs the medication. That “rebate” the drug companies offer would otherwise go straight to the patient, not the PBM. In 2015, as much as $106 billion in rebates went straight to those PBMs, not the patients. This means that you may be paying out of pocket for the medication you need, but many cannot afford those high costs. Earlier this year, the Utah Legislature considered changing this practice to pass those rebates to the customers at the pharmacy counter instead. At the last minute, the bill did not pass. I’m a nurse practitioner, which means that I wear many hats. But I was not trained as a financial counselor. When I’m talking to patients about the medications that could help them live healthier, happier lives, I should be able to prescribe the medication that I need to without having to worry about which insurance company bureaucrats are taking how much of a percentage. And my patients shouldn’t have to worry about that either. PBMs restrict medical practice and your access to medications. Ask your legislator to put some action behind those “clap for our heroes” gestures of gratitude so that you can get the care that you need. Because what I’d like to do most is focus on helping people like you. That’s what I do. Melissa J. Hinton, Salt Lake City, is president of Utah Nurse Practitioners and has a doctor of nursing practice degree from the University of Utah. Ohio Capitol Journal
Ohio Medicaid, which provides health care to more than a quarter of the state’s population, is poised to take a big step in a major overhaul of the program. Gov. Mike DeWine on Tuesday said that on Wednesday a request for applications will hit the streets seeking pitches from companies to manage the care of more than 90% of Ohio Medicaid recipients. “This is the first major overhaul of Medicaid in 15 years,” DeWine said. That might be overstated. In 2013, under former Gov. John Kasich, Ohio greatly expanded the Medicaid rolls under the Affordable Care Act. It was one of several big changes to Medicaid over the years. At present, five care organizations manage the bulk of the $27 billion Ohio Medicaid spends annually. But DeWine said state officials have been in the field for months, meeting with patients, providers such as doctors, dentists and pharmacists, as well as the companies that manage the care plans. “From these conversations and this process, we have developed a new plan, a new vision, for Ohio’s Medicaid program, one that focuses on people and not just on the business of managed care,” he said. “A vision of what we hope will be a better, healthier, more productive state of Ohio.” The governor said Medicaid will also restructure its programs for children with serious behavioral health problems. The reforms are ambitious and they were praised by some policy experts as long overdue. “Frankly, I’m happy to see (this) move forward,” tweeted Loren Anthes, who leads the Cleveland-based Center for Community Solutions’ Center for Medicaid Policy. “It’s been long overdue need for the state to revisit these valuable contracts. Devil’s in the details, but we could be doing a lot better than we are. I can’t wait to review the proposal.” However, some others have questioned whether the Medicaid’s leadership has the bandwidth to complete the overhaul by next summer, when it’s supposed to be complete. Not only is the state in the midst of a historic pandemic, the department has failed to meet important deadlines to disburse supplemental payments to pharmacists and to create a single pharmacy benefit manager. Continue Reading National Law Review
The regulation of drug prices has received significant recent bipartisan support in Congress. Democrats and Republicans in both houses have proposed approximately eighty bills relating to drug pricing over the past two years. The charts below summarize the key provisions of representative bills.[i] Although the proposed price-regulating mechanisms differ from bill to bill, the bills do not indicate a clear difference in the parties’ goals when viewed at a high level. Many of the proposed bills focus on price transparency as well as reporting to the Department of Health and Human Services (HHS). Certain bills would require pharmaceutical manufacturers to provide data on, and justifications for, the pricing of certain drugs that would exceed specified price increase limits. These bills usually include penalties for reporting failures; however, they usually do not provide a procedure to lower a price that triggers the reporting provisions. Instead, they often establish or enhance public databases for the reported information, and some go as far as requiring pharmacists to communicate this information to the patient at the point of sale. Other proposed bills would set caps on drug pricing, albeit through different approaches. Certain bills would require HHS to negotiate drug prices with the manufacturers of covered drugs, for example, and some of these bills grant HHS the power to establish a price if an agreement is not reached. Although many bills on this topic have been proposed throughout the current legislative session, most are stalled in committee, often since their day of.” Senate Bills S. 3384 Lowering Prescription Drug Prices for America’s Seniors and Families Act of 2020 Sen. Martha McSally (R-AZ) 03/03/2020 Referred to Committee on Finance
S. 3166 Prescription Drug Affordability and Access Act Sen. Cory Booker (D-NJ) 01/08/2020 Referred to Committee on Health, Education, Labor, and Pensions
S. 3129 Lower Costs, More Cures Act of 2019 Sen. Mike Crapo (R-ID) 12/19/2019 Referred to Committee on Finance.
S. 2543 Prescription Drug Pricing Reduction Act of 2019 Sen. Chuck Grassley (R-IA) 09/25/2019 Legislative Calendar under General Orders (Calendar No. 225) S. 4199 (introduced 07/02/2020) reintroduces S. 2543
S. 1987 End Price Gouging for Medications Act Sen. Jeff Merkley (D-OR) 06/26/2019 Referred to Committee on Health, Education, Labor, and Pensions
S. 1664 Prescription Drug Price Reporting Act Sen. Rick Scott (R-FL) 05/23/2019 Referred to Committee on Health, Education, Labor, and Pensions
S. 1437 Drug-price Transparency in Communications (DTC) Act Sen. Richard J. Durbin (D-IL) 05/13/2019 Referred to Committee on Finance
S. 1391 Fair Accountability and Innovative Research Drug Pricing Act of 2019 Sen. Tammy Baldwin (D-WI) 05/09/2019 Referred to the Committee on Health, Education, Labor, and Pensions
S. 977 Transparent Drug Pricing Act of 2019 Sen. Rick Scott (R-FL) 04/01/2019 Referred to Committee on Health, Education, Labor, and Pensions
S. 709 Prescription Drug Pricing Dashboard Act Sen. Robert P. Casey, Jr. (D-PA) 03/07/2019 Referred to Committee on Health, Education, Labor, and Pensions
S. 637 CURE High Drug Prices Act Sponsor: Sen. Richard Blumenthal (D-CT) 02/28/2019 Referred to Committee on Health, Education, Labor, and Pensions
S. 474 Stopping the Pharmaceutical Industry from Keeping drugs Expensive (SPIKE) Act of 2019 Sen. Ron Wyden (D-OR) 02/13/2019 Referred to Committee on Finance
S. 378 Stop Price Gouging Act Sen. Sherrod Brown (D-OH) 02/07/2019 Referred to Committee on Finance
S. 102 Prescription Drug Price Relief Act of 2019 Sen. Bernard Sanders (I-VT) 01/10/2019 Referred to Committee on Health, Education, Labor, and Pensions
S. 99 Medicare Drug Price Negotiation Act Sen. Bernard Sanders (I-VT) 01/10/2019 Referred to Committee on Finance
S. 62 Empowering Medicare Seniors to Negotiate Drug Prices Act of 2019 Sen. Amy Klobuchar (D-MN) 01/09/2019 Referred to Committee on Finance
House Bills H.R. 5281 Drug Price Transparency in Medicaid Act of 2019 Rep. Earl L. Carter (R-GA-1) 12/04/2019 Referred to the Subcommittee on Health
H.R. 5239 Prescription Drug Price Reporting Act 11/21/2019 Rep. David P. Joyce (R-OH-14) 11/22/2019 Referred to the Subcommittee on Health
H.R. 5039 Life-Sustaining Prescription Drug Price Relief Act of 2019 Rep. Daniel Lipinski (D-IL-3) 11/13/2019 Referred to Subcommittee on Health.
H.R. 4640 Affordable Pricing for Taxpayer-Funded Prescription Drugs Act of 2019 Rep. Peter A. DeFazio (D-OR-4) 10/14/2019 Referred to Subcommittee on Health
H.R. 3 Elijah E. Cummings Lower Drug Costs Now Act Rep. Frank Pallone, Jr. (D-NJ-6) 12/12/2019 Passed House Senate – 09/08/2020 Placed on Legislative Calendar (General Orders, Calendar No. 521)
H.R. 3379 Price Relief, Innovation, and Competition for Essential Drugs Act Rep. Janice D. Schakowsky (D-IL-9) 06/21/2019 Referred to the Subcommittee on Health
H.R. 2115 Public Disclosure of Drug Discounts and Real-Time Beneficiary Drug Cost Act Rep. Abigail Davis Spanberger (D-VA-7) 10/28/2019 Passed House Senate – 10/29/2019 Committee on Finance
H.R. 2087 Drug Price Transparency Act Rep. Lloyd Doggett (D-TX-35) 05/21/2019 Subcommittee hearings
H.R. 987 Strengthening Health Care and Lowering Prescription Drug Costs Act Rep. Lisa Blunt Rochester (D-DE-At Large) 05/16/2019 Passed House Senate – 05/20/2019 Committee on Health, Education, Labor, and Pensions
H.R. 448 Medicare Drug Price Negotiation Act Rep. Elijah E. Cummings (D-MD-7) 09/25/2019 Subcommittee Hearings Held
H.R. 275 Medicare Prescription Drug Price Negotiation Act of 2019 Rep. Peter Welch (D-VT-At Large) 09/25/2019 Subcommittee Hearings Held
[1] The charts above summarize selected drug pricing bills put forth in the 116th Congress. Although these lists are not exhaustive, they provide examples of the types of price-regulating measures under consideration. These bills were identified by searching congress.gov for the terms “drug pricing” and “drug price.” EIN Presswire
Pharmacies Allege OptumRx Knowingly Paid Them Less Than Large Retail Chain Pharmacies and Misused Patient Information The newest litigation against a major pharmacy benefit manager comes from a most likely source: their small business victims. Unwilling to tolerate the low reimbursements which threaten to drive them out of business, more than 30 California independent pharmacies have sued pharmacy benefit manager (PBM) OptumRx, a division of UnitedHealth Group, charging the company violated California laws by paying them less than their acquisition costs and illegally steering their patients to Optum’s own mail-order pharmacy. The lawsuit alleges that OptumRx ignored California law, unlawfully paid California pharmacies substantially less than it paid large chain retail pharmacies - like CVS or Walgreens - and its own mail-order pharmacy for the same prescriptions. The lawsuit further alleges that OptumRx deliberately reimbursed these independent California pharmacies below their wholesale cost to acquire generic prescription drugs necessary for their patients. PBMs administer the prescription drug portion of health insurance and self-insured plans, acting as a middleman between the insurance plan and the pharmacist. Over the last 20 years, these companies have accumulated immense, unregulated power - the three largest PBMs controlling over 80% of the healthcare market - and have utilized that power to increase prescription drug costs, decrease competition, and restrict patient choice. Paying independent pharmacies less than their acquisition and dispensing costs is likely one reason why OptumRx is the most profitable component of UnitedHealth Group; the world’s largest health insurance company, with over $225 billion in annual revenues. The California pharmacies in the lawsuit allege that: PBMs dictate reimbursements without notice or negotiation, and the dictated rates are often unrelated to the pharmacies’ actual wholesale costs to acquire the drugs for their patients. Sometimes for a prescription filled by the pharmacy, Optum charges the patient’s health care plan the brand price while paying pharmacies the lower generic price for each prescription. This allows Optum to collect huge profits on prescriptions merely by changing their classification. Optum built a wall of secrecy around its conduct by forcing network pharmacies into confidentiality agreements that conceal the truth - specifically how much Optum is paid by insurance plans for prescriptions, how much Optum receives in rebates from drug manufacturers, and how little Optum pays to pharmacies who actually serve the patients and dispense the drugs. Optum illegally takes patient information it receives from independent pharmacies through the claims process and uses it to steer those customers to Optum’s own mail-order pharmacy. The survival of independent pharmacies in the U.S. healthcare system is seriously threatened by the unethical, predatory business practices of PBMs. This lawsuit seeks to break this wall of secrecy and hold Optum accountable. The California pharmacies are represented by Mark Cuker and Neal Jacobs of the Jacobs Law Group, and the California firm of Barrack, Rodos, and Bacine. Cuker and Jacobs also represent over 500 independent pharmacies in lawsuits pending in Pennsylvania and Illinois. For more information about the Independent Pharmacies vs. PBM lawsuits, contact Mark Cuker at (215) 531-8512 or 215-569-9701. # # # Mark R Cuker, Esq Jacobs Law Group +1 215-569-9701 email us here Bloomberg Law
Cigna Health & Life Insurance Co. convinced a federal judge in Connecticut to trim a proposed class action claiming the insurer schemed with pharmacy benefit manager OptumRx Inc. to overcharge health plan participants for prescription drugs. Judge Jeffrey Alker Meyer of the U.S. District Court for the District of Connecticut on Monday dismissed Billy Ray Blocker’s state law claims alleging breach of contract and breach of the implied covenant of good faith and fair dealing. Cigna isn’t a party to Blocker’s health plan, which is self-funded by a county government in suburban Atlanta, and there’s no indication Cigna assumed any obligations under the health plans between Blocker and the county, Meyer said. Meyer’s ruling addressed only two of the lawsuit’s 10 counts. The lawsuit accuses Cigna and other defendants of scheming to overcharge people for prescription drugs, sometimes by as much as 300%. The lawsuit claims that when a given prescription drug costs less than a patient’s copayment amount, the insurer “claws back” the difference through an improper scheme kept hidden from patients. This sometimes causes insured patients to pay more for drugs than they would without insurance, with pharmacists contractually prohibited from telling patients this information, according to the lawsuit. The lawsuit was allowed to proceed over Cigna’s motion to dismiss in 2018. Other insurers have been accused of similar violations. UnitedHealth Group Inc. defeated a clawback lawsuit in 2017. Humana entered into a confidential settlement in 2018, and cases against CVS Health Corp. and Walgreens Boots Alliance were voluntarily dismissed. The health plan participants are represented by Zimmerman Reed PLLP; Whitfield, Bryson & Mason LLP; Keller Rohrback LLP; Izard, Kindall & Raabe LLP; Scott & Scott LLP; Motley Rice LLC; Sarraf Gentile LLP; and Lockridge, Grindal, Nauen PLLP. Cigna is represented by Morgan, Lewis & Bockius LLP. The case is Negron v. Cigna Health & Life Ins. Co., 2020 BL 331303, D. Conn., No. 3:16-cv-01702, 8/31/20. To contact the reporter on this story: Jacklyn Wille in Washington at jwille@bloomberglaw.com |
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