The California Court of Appeal, First Appellate District has just affirmed the holding of a trial court that Optum’s arbitration clause in its manual is unconscionable and unenforceable.
I have previously covered this case here. But in a nutshell, a group of California pharmacies brought a case against Optum alleging misrepresentation, fraud, and breach of
For a long time, reimbursement for specialty drugs have been a subject of heated debates and controversies. A reason for this could be a lack of clear definition of what constitutes a specialty drug. Recently, a Seattle pharmacy brought a case against Express Scripts, Inc. (ESI) revolving around the issue of underpayment for specialty drugs
Earlier this year, CMS issued its Medicare Part D Final Rule addressing DIR fees, among other things. It is important to remember that the rule does not eliminate DIR fees but moves them to the point of sale. The rule becomes effective January 1, 2024, meaning that the pharmacies will face a DIR cliff when
This is something we (those who own or work for independent pharmacies) have been waiting for. Finally someone was bold (and brave) enough to bring an action against a PBM on DIR fees. This someone is Aids Healthcare Foundation (“AHF”), a California non-profit, which owns and operates retail pharmacies that serve HIV/AIDS patients. While many
Similarly to a recent California case that denied Optum’s motion to compel arbitration, the 12th Circuit Court has denied a similar motion due to procedural and substantive unconscionability.
In a nutshell, 45 pharmacies brought a legal action against Optum claiming underpayment since 2012 (as in the California case, Mark Cuker represents the pharmacies). To stall
Back in 2020, I wrote a blog post on potential PBM audit issues and disciplinary actions based on purchasing diabetic test strips from unauthorized wholesalers. The problem is still prevalent. In fact, during these past few months, we have seen several manufacturers sending cease-and -desist letters to pharmacies demanding money for lost sales and threatening
PBMs often flag telehealth claims and scrutinize the legitimacy of such scripts. When we see chargebacks based on “Invalid patient/prescriber relationship,” we know that it’s time for some legwork. We typically research (1) where the prescriber and patient were located; (2) whether prescriber was authorized to prescribe the medication in question; and (3) whether the
Automatic refills is a landmine. Some states prohibit them outright. Medicare requires patient consent before each delivery. Most PBMs also place some conditions on auto-refills, such as obtaining authorization from the patient for each refill (to prevent fraud, waste and abuse and to ensure that patients receive only medications that they have requested). PBM manuals
I am very excited to announce a release of Gavel & Pestle podcast where I speak on PBM audits, trends, and litigation. With Brooke Kulusich we discuss the most common compliance mistakes that pharmacies make, the implications of Rutledge v. PCMA decision, and how independent pharmacies can think outside-the-box in their approach to PBMs.
Please
This year we saw some positive litigation outcomes for independent pharmacies. Let’s talk about two recent victories in PBM litigation. (Both cases were brought by Mark Cuker who represents several groups of pharmacies across the nation).
One of the cases was brought in California against Optum alleging misrepresentation, fraud, and breach of contract. Optum filed