Optum Rx to pay $5.8M for not following pricing procedures

The Massachusetts Attorney General’s Office announced that pharmacy benefits manager Optum Rx agreed to pay $5.8 million to settle a claim that it failed to follow workers compensation prescription drug pricing procedures.

However, Optum did not admit any of the alleged wrongdoing in the settlement filed Wednesday.

“The settlement, filed in Suffolk Superior Court, resolves allegations that Optum Rx, in some circumstances, failed to apply various regulatory benchmarks — like the federal upper limit for Medicare and the Massachusetts maximum allowable cost — to its pricing determinations for certain workers’ compensation insurance prescription drug charges,” the attorney general’s office said. “These failures, according to the settlement, allegedly occurred on various injured worker prescriptions filled in Springfield, New Bedford, Boston and Worcester at Walgreens, CVS and RiteAid locations.”

Optum Rx pays pharmacies that fill prescriptions for injured workers and charges insurers and self-insured employers for the drugs through the work comp system. The Attorney General’s Office argued that not following the regulatory processes intended to prevent overcharging “allowed excessive drug costs to enter the workers compensation insurance system.”

In addition to the $5.8 million payment, the terms of the settlement also require Optum Rx to ensure that billings and payments comply with state law and regulations going forward. To facilitate compliance, Optum Rx must develop a pricing protocol that is described in more detail in a separate agreement with the state’s top prosecutor, according to the settlement.

The company also agreed to cooperate with the attorney general’s office in future compliance monitoring efforts.

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