Woman Files Humana Lawsuit, Claims Inflated Rx Prices

An Alabama woman has filed a Humana lawsuit against the pharmaceutical company claiming that she and others paid inflated rates for prescription drugs because of Humana’s fraudulent system for copayments.

Plaintiff Margie W. brought the Humana lawsuit saying she participated in a Medicare Advantage Part D health plan that was offered and managed by Humana, Inc. and Humana Pharmacy Solutions.

She claims she was injured by Humana by paying inflated copayments for medically necessary, covered prescriptions.

According to Margie’s Humana lawsuit, about 90% of Americans are enrolled in private or public health insurance plans that cover some or all of the costs of prescriptions and medical procedures.

Most often, the cost of prescription drugs are shared by the health insurance provider. Usually, when a patient fills a prescription for a medically necessary, covered drug under his or her health plan, the plan pays a portion of the cost. The remainder is paid directly to the pharmacy in the form of a copayment, or copay.

A copay, according to the Humana lawsuit, is a small fixed fee that a health insurer requires the patient to pay for certain covered medical expenses. Pharmacies must collect the copay and are not allowed to waive or reduce the copay collected.

Humana Lawsuit Alleges Fraudulent CoPay Scheme

Humana is both an insurer and a pharmacy benefit manager (PBM). They have been accused of engaging in a scheme to defraud plan members, like Margie and others, by artificially inflating the copayment well above what the drug costs.

Margie claims that Humana inflated the purported costs of the drugs by increasing copayments and then “clawing back” or recouping a large portion of the copays from the pharmacies.

The Humana lawsuit alleges that plan participants believe that the copayment is based in some part on the cost of the actual drug, when in fact the copayment is inflated and the defendants pocket the overpayments in the form of clawbacks.

Allegedly, Humana has represented to pharmacies that customers overpaid and they are clawing back the increased payments. However, this was never disclosed to plan participants.

This claw back money is pure profit for Humana, the Humana lawsuit claims.

What is even more, Margie notes, is that Humana’s contracts with participating pharmacies require that pharmacists do not disclose to customers the existence of a claw back or the fact that the actual cost of the drug to the consumer may be lower if he or she did not utilize insurance.

This is called a “gag clause,” according to this Humana lawsuit, and prohibits pharmacies from advising insured customers that they could pay less for a drug if the purchase was made without the applied insurance benefit.

The plaintiff is raising claims of negligent misrepresentation, fraud, violation of the Kentucky Consumer Protection Act as well as violation of the Racketeer Influenced and Corrupt Organizations Act (RICO).

The Humana Lawsuit is Case No. 3:16-cv-706-GNS filed in the U.S. District Court in the Western District of Kentucky.

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