Optum Emails Present PBM Knew of Drug Reimbursement Points, AG Says| Staff Compensation Information

Tuesday, December 29, 2020 | 82 | 0 | min read

Emails uncovered in Ohio’s lawsuit against OptumRx suggest the pharmacy services management company knew it was overloading the state’s employee compensation scheme, the Ohio Attorney General said.

Columbus Dispatch reported Sunday that emails show that the PBM breached its contract with the Bureau of Workers’ Compensation by not sticking to the lowest available rate for reimbursement of prescription drugs. The deal reportedly required Optum and Catamaran, a PBM acquired by Optum, to charge BWC the lowest of four available generic prices.

One of those potential price levels was known as the Federal Upper Limit, as set by the U.S. Centers for Medicare and Medicaid Services. However, a confidential email from a catamaran official indicates that the federal ceiling has not been taken into account.

“BWC is not aware of this (yet),” wrote John Spankroy, director of public sector account management at Catamaran, in the email to another company official.

“The approval is of great importance” to “whether OptumRX was required to meet the price terms contained in the BWC contract,” said attorneys for Ohio Attorney General Dave Yost in a December 16 court case.

An Optum spokesman said the federal price limit known as FUL was never stipulated in the contract with the state Comp insurer.

“The plain language of the contract shows that the lesser reimbursement method agreed and used by the parties over their nearly ten-year relationship included three reimbursement options, and CMS FUL was never one of them. “OptumRx said in a lawsuit.

The lawsuit alleges Optum overloaded BWC for more than 1.3 million prescription reimbursement claims, which cost the insurance agency more than $ 16 million. A trial date for the lawsuit has been postponed to the end of 2021.