Suit alleges insurance managers’ negligence

The cities of Huntington, Charleston and Kenova and the town of Ceredo are suing a group of PEIA insurance management companies and pharmacies they said accepted “blood money” from drug distributors in exchange for ignoring requests to thoroughly check patients’ opioid prescriptions.

Defendants named in the lawsuit are Express Scripts Holding, Express Scripts Inc., McCloud Family Pharmacy Inc., T&J Enterprises Inc., Continuumcare Pharmacy LLC, Medical Park Pharmacy LTC Inc., West Virginia CVS Pharmacy LLC, MRNB Inc. and Rxbytel Inc.

The Express Scripts defendants are identified as pharmacy benefit managers who were hired by employers, health plans, unions and others to work with drug manufacturers to process prescription claims.   As managers the companies are able to determine how much of which drug goes where in the United States through formularies and insurance tiers.    The lawsuit states because of this, pharmacy benefit managers and insurance plans favor opioids over non-addictive alternatives.

The remaining defendants are pharmacies that distribute opioids in the plaintiff cities’ areas.  The lawsuit civilly charges the defendants with gross negligence, reckless and willful conduct, and unjust enrichment.

“The acceptance of this funding in the context of rebates from the opioid manufacturers co-opted the defendants so that they failed to recognize the dangerous and addictive nature of opioids and encouraged the over-prescription of opioid medications in lieu of less addictive alternatives,” the complain said.

The lawsuit complaint alleges the West Virginia Public Employees Insurance Agency (PEIA) has started in 2001 to ask Express Scripts, which served as a pharmacy benefit manager to PEIA, to require prior authorization for oxycodone prescriptions for state employee health plan users.  With prior-authorization of pharmaceutical prescriptions, studies have shown a 15 percent reduction of opioid prescribing, according to the lawsuit.

“The drug epidemic is in part the result of Express Scripts’ enthusiasm, as far back as 2001 and continuing to this day, to suborn its own client’s efforts to minimize opioid prescribing in favor of accepting continued payments from opoioid manufacturers to foster continued over-prescription of opioids,” the complaint states.

While pharmacy benefit managers started as a theory about 15 years ago to get insurance holders a better price on pills, they have since “consolidated their position at the intersection of drug manufacturers, pharmacies and patients to exert tremendous power over the entire drug supply chain,” the lawsuit alleges.

While working for employers and others, the pharmacy benefit managers are also able to generate an income from drug manufactures, as well as their clients, the lawsuit states.  The pharmacy benefit managers negotiate payments from drug manufacturers in the form of rebate discounts on specific drugs in exchange for favorable payment of the manufacturers’ drugs within the insurance formularies.

The lawsuit specifically accuses the pharmacy benefit managers of ignoring PEIA’s request for prior-authorization of OxyContin pills because of payments from Purdue Pharma.

The plaintiffs are seeking a jury trial and monetary judgement for repayment of the cost of the opioid epidemic, including costs to provide human services to the community, respond to health emergencies and public safety costs.

Controlling the damage caused by the region’s opioid epidemic would take an estimated $166 million in additional investments toward substance use treatment as well as economic redevelopment in the Huntington-Ashland metropolitan areas, according to research by the Marshall University John C. Edwards School of Medicine.