Approximately 20 pharmacies across Ventura county filed a lawsuit against their Pharmacy Services Administrative Organizations (PSAOs) – Arete, Elevate, and Leadernet – for allegedly conspiring with OptumRx in reducing reimbursement rates.

The pharmacies allege that PSAOs owe fiduciary obligations to independent pharmacies to protect their interests against PBMs. PSAOs allegedly failed to negotiate acceptable rates for pharmacies by signing PBM contracts reimbursing pharmacies below the cost.

OptumRx is also a part of the lawsuit under a separate cause of action under Unfair Trade Practices for negative reimbursements and spread pricing. OptumRx has a large presence in Ventura County serving Gold Coast Health Plan, providing drug benefits to approximately 200,000 low-income Medi-Cal beneficiaries.

Ventura Star reports that prior to filing the lawsuit, the pharmacies complained multiple times to Ventura County Medi-Cal Managed Care Commission about below-market rates and the shut-down of several independent pharmacies due to the inability to stay in business. An independent consultant reviewed the rates and reported to the Commission that Optum’s rates are comparable to payments in similar Medicaid plans. The commission refused to direct OptumRx to raise its rates.

Pharmacies allege that OptumRx conspired with PSAOs to force low reimbursements on the pharmacies by inventing its own MAC list “based on thin air.”

OptumRx defended its reimbursement methodology in a public statement:

            “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…We believe this    lawsuit is without merit and will vigorously defend ourselves.”

Because most pharmacy contracts with PSAOs and PBMs have arbitration provisions, the case may end up in arbitration. We will be watching how the case unfolds and will report of any developments.