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Life Health > Health Insurance > Life Insurance Strategies

PBM Resolves Drug Shift Investigation

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A pharmacy benefits manager has agreed to settle an investigation related to efforts to switch patients from one cholesterol-control drug to another.

Express Scripts Inc., St. Louis, will pay $9.5 million to the 29 participating jurisdictions in connection with an assurance of voluntary compliance and discontinuance, the company says.

The states will get $9.3 million of the cash, and $200,000 will be spent on patient tests and office visits related to the drug switches, Express Scripts says.

Express Scripts also has agreed to changes in business practices, according to Pennsylvania Attorney General Thomas Corbett Jr.

Express Scripts cannot solicit drug switches when the net drug cost of the proposed drug exceeds the net drug cost of the originally prescribed drug, the originally prescribed drug has a generic equivalent and the proposed drug does not, or the patient was switched from a similar drug within the last 2 years, officials say.

Express Scripts must tell patients and prescribers what effect a drug switch will have on a patients co-payment; tell prescribers of Express Scripts’ financial incentives for certain drug switches; warn prescribers about material differences in side effects or efficacy between prescribed drugs and proposed drugs; and monitor the effects of drug switches on the health of patients, officials say.

Officials in Pennsylvania, 27 other states and the District of Columbia began looking at Express Scripts’ management of cholesterol-control prescriptions in 2004:

Jurisdiction officials have accused Express Scripts of engaging in “deceptive business practices by not always acting in a manner consistent with its representations to consumers and employers about its pharmacy benefit management services,” officials say. “In particular, Express Scripts may have overstated the cost benefits of switching to certain preferred medications.”

Express Scripts says it “does not admit any of the assertions made by the attorneys general.”

The investigation by the attorneys general did not lead to litigation, and the assurance of voluntary compliance “precludes future litigation against the company by the attorneys general under state consumer protection and antitrust laws in areas that were the subject of the investigation,” Express Scripts says.

Express Scripts’ client disclosures have been “forthright and adequate,” and the company’s business practices already comply with most of the agreement business practice requirements, Express Scripts says.

“Only minor adjustments in certain procedures will bring [the company] into full compliance,” Express Scripts says.

In addition to Pennsylvania and the District of Columbia, the participating jurisdictions include Arizona, Arkansas, California, Connecticut, Delaware, Florida, Illinois, Iowa, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nevada, New Mexico, North Carolina, Ohio, Oregon, South Carolina, South Dakota, Tennessee, Texas, Vermont, Virginia and Washington.


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