Dive Brief:
- Optum Rx, one of the largest pharmacy benefit managers in the U.S., has agreed to pay the Department of Justice $20 million to settle allegations it filled illicit opioid prescriptions, ignoring the risk of harm to patients.
- Between 2013 and 2015, Optum Rx filed orders for opioids, benzodiazepines and muscle relaxants — known as the “holy trinity” of drugs due to their likelihood of abuse — despite most of the prescriptions coming from the same mail-order pharmacy, raising red flags, according to an investigation by the Drug Enforcement Agency.
- Many of those prescriptions were filled without Optum Rx addressing those red flags, the DEA found. Optum Rx did not admit guilt as part of the settlement, which at $20 million is essentially a slap on the wrist — the PBM, a subsidiary of healthcare behemoth UnitedHealth, brought in $116 billion in revenue last year.
Dive Insight:
The government’s case against Optum Rx hinges on the Controlled Substances Act passed in 1970, which requires pharmacies providing certain drugs with a risk of abuse to make sure they’re filling prescriptions only for legitimate medical purposes.
However, Optum Rx — mostly through a mail-order pharmacy in Carlsbad, California — allegedly filled “numerous” holy trinity prescriptions with significant risk of harm without resolving concerns that they could be abused or diverted, according to the DOJ’s release on Thursday.
Since 2017, Optum Rx says it has put stricter opioid prescription protocols in place, along with heightened utilization review processes to identify excess opioid dispensing, the DOJ said. Optum Rx has also shuttered its mail-order pharmacy operations in Carlsbad.
Much of the blame for the nation’s deadly opioid epidemic has fallen on the manufacturers that made and marketed the highly addictive pills, the doctors who prescribed them and the pharmacies that dispensed them. However, PBMs are increasingly being fingered for their role in perpetuating the crisis.
PBMs sit in the middle of the U.S. drug supply chain. The companies contract with pharmaceutical manufacturers to place drugs on formularies in return for discounts, administer health plans’ pharmacy benefits and contract with pharmacies to dispense medications to covered members.
News of the settlement comes days after Optum Rx was sued by Arkansas for business practices that allegedly increased access to opioids during the height of the epidemic.
Alaska and Nebraska, along with a handful of counties, including in California, Ohio, Texas and Virginia, have also sued PBMs for their alleged role in furthering the crisis.
Almost 645,000 people died from an overdose involving an opioid from the start of the epidemic in the late 1990s through 2021, according to the Centers for Disease Control and Prevention.
Opioid litigation, including against PBMs, is being consolidated in front of a federal judge in Ohio. Many major cases have already been settled, resulting in roughly $50 billion in restitution flowing to plaintiffs.
However on Thursday, the Supreme Court overturned a $6 billion settlement with opioid manufacturer Purdue Pharma, finding it improperly protected the Sackler family from legal claims. As a result of the ruling, settlement talks with the Sacklers will resume again while Purdue’s bankruptcy proceedings continue separately.
