Independent pharmacists across Ventura County have filed a lawsuit against OptumRx, alleging the company manipulated drug pricing to enable lower reimbursement rates paid to small drugstores and plunging businesses underwater.
OptumRx, one of the biggest operations of its kind in the United States and part of the UnitedHealth network, sets payment rates as the pharmacy benefit manager for the Gold Coast Health Plan. The publicly funded Gold Coast organization provides Medi-Cal insurance to nearly 200,000 low-income Ventura County residents.
The pharmacists allege the company used contracts negotiated with agents of pharmacies to force the businesses into accepting payment that often fell below costs. OptumRx threatened people who pushed back with expulsion from the network, the complaint stated.
The lawsuit alleges unfair trade practices, breach of contract and violation of California law. It was filed by 18 companies and individuals in Ventura County Superior Court.
The litigation also targets three pharmacy services administration organizations – operated by Cardinal Health, Arete Pharmacy Network and AmerisourceBergen – that worked as middlemen between the pharmacies and OptumRx.
Leaders of OptumRx have repeatedly defended their pricing in a drama that dates back to last summer, shortly after the company assumed its role as Gold Coast’s pharmacy benefit manager.
“OptumRx’s role is to ensure consumers and health plan payers have convenient access to affordable prescription medications, and we will continue to work to help lower health care costs for Gold Coast Health Plan and California taxpayers,” said OptumRx spokesman Drew Krejci in a statement Thursday. “We believe this lawsuit is without merit and will vigorously defend ourselves.”
Pharmacists have crowded meetings of the Ventura County Medi-Cal Managed Care Commission for months, complaining about below-market rates they say shut down the Medical Plaza Pharmacy in Fillmore and put many others in jeopardy. The commission governs Gold Coast.
An independent consultant reviewed the rates and told the commission in April that the reimbursement paid by OptumRx is comparable to payment in similar Medicaid plans in California and elsewhere. After a closed-door discussion, commissioners announced they would not try to force the pharmacy benefit manager to raise the rates.
The lawsuit alleges OptumRx won the Gold Coast contract because it offered price guarantees and met the guarantees by obtaining secret rebates from drug makers and then manipulating pricing.
OptumRx also used something called the “maximum allowable cost” list to force reimbursement down, pharmacists claim. The so-called MAC list helps set the reimbursement rate and is supposed to be influenced by prices different distributors ask for the same generic medication. The pharmacists allege OptumRx ignored market prices and made up its own maximum allowable cost “based on thin air.”
It is “a moving target moved at Optum’s whim,” the lawsuit stated. It alleged OptumRx also kept its MAC price for generic drugs secret and violated state law by not making decisions on appeals by pharmacists within seven business days.