The Mississippi Board of Pharmacy’s audit of Optum’s 2022 commercial claims continues to make news. The article points out how consumers were almost twice as likely to pay the full cost of a prescription drug claim without contributions from their insurance plan at independent pharmacies than at affiliated pharmacies. As NCPA previously reported, several potential violations of state law were also identified in the audit.
Among the apparent violations, more than 75,000 claims were reimbursed at higher rates to PBM-owned or affiliated pharmacies during the study period. In reviewing the 49 MAC lists used by Optum, 22 were exclusive to chain pharmacies and 15 were specific to independent pharmacies. Within these lists, the board found the average independent MAC rates were 74 percent less than those of chains, with 97.7 percent of generics on MAC lists for independents versus 88 percent for chains. Meanwhile, more than 98 percent of MAC appeals were denied, many of which the board views as in conflict with statute.
According to the article, there will be an administrative hearing with Optum on Dec. 19. Administrative proceedings are also scheduled with Express Scripts and CVS Caremark on Nov. 21.
