Optum Rx, UnitedHealth’s PBM, sued by independent pharmacy over backdoor fees

An independent Iowa pharmacy has filed a class-action lawsuit against UnitedHealth Group and Optum Rx, its pharmacy benefit manager, for allegedly pressuring pharmacies to agree to “unconscionable” performance-based fees.

These direct remuneration fees, or DIR, allow PBMs to retroactively adjust how much pharmacies are reimbursed based on their quality performance. In the lawsuit, Osterhaus Pharmacy said OptumRx forces pharmacies to accept one-sided contracts or lose access to millions of potential customers with pharmacy benefits through the PBM.

The lawsuit alleges that Optum Rx sets performance metrics and calculates DIR fees, which pharmacies are forced to pay to remain in its network for Medicare Part D. These fees are unfair, the lawsuit says, because they rely in part on metrics that pharmacies don’t control, such as patient outcomes or which drugs a doctor chooses to prescribe.

The suit seeks class-action status to include thousands of independent pharmacies with similar contracts with Optum Rx. It wants to recover treble damages, the cost of the lawsuit and reasonable attorneys’ fees for Optum Rx’s alleged violations. Osterhaus brought a similar suit against CVS in September.

“Many of the performance criteria established by OptumRx make little or no sense for pharmacies,” the lawsuit said. “To serve the millions of beneficiaries enrolled in OptumRx‐affiliated plans, independents generally have no practical choice but to participate in the Optum Rx network.”

Optum Rx denied the premise of the lawsuit. “We are proud to partner with community pharmacies across the country to deliver care, improve the pharmacy experience and provide our members with access to the lowest possible cost for drugs and best possible care,” a company statement said. “This lawsuit is without merit, and we will defend against these allegations.”

Related: ‘It’s payback time!’ Community pharmacies unite to fight PBMs over ‘junk’ fees

However, the National Community Pharmacists Association applauded the legal action. “After years of abuse at the hands of big insurance plans and their PBMs, independent pharmacies are fighting back,” CEO B. Douglas Hoey said. “It’s very common for individual pharmacies to pay hundreds of thousands of dollars a year in fees that they can’t anticipate, and in many cases long after the point of sale. They’re putting small, independent pharmacies out of business, thereby limiting choice and quality for consumers, and we are optimistic that these legal challenges will finally bring some justice to this self-serving practice.”

Independent pharmacies have been closing across the United States, especially in rural areas, because of increased financial pressures. Currently, almost half of U.S. counties are considered pharmacy deserts as a result of these closures, according to an analysis by drug coupon company GoodRx.