CVS Health Certain Medicare beneficiaries were deliberately blocked from getting cheaper generic prescriptions, according to a whistleblower lawsuit by a former CVS executive. The lawsuit papers were recently unsealed.
“In doing so, CVS Health secured its own staggering profits while passing the increased costs on to taxpayers and Part D beneficiaries,” the whistleblower alleges in a complaint filed in March, which was published Thursday by Stat news.
The lawsuit alleges that the fraudulent scheme disproportionately affected older patients with end-stage renal failure. And forcing many beneficiaries of the SilverScript Part D program not to receive critical care because they cannot get generic versions of the necessary drugs at affordable costs. SilverScript Provides a prescription drug plan for Medicare Part D. CVS Health has denied the allegations.
The case has brought intense attention to pharmacy benefit managers, who are often derided as middlemen in the industry, especially given that large PBMs are owned by entities that are also payers, and if patients pay more for their drugs, they will win. In this case, PBM’s CVS Caremark is owned by CVS Health, which also owns insurance company Aetna. After initially refusing to do so, Federal Trade Commission announced earlier this month The agency is launching an investigation into PBM and an alleged conflict of interest.
Medicare Part D helps patients pay for generic and brand-name drugs. Unlike other Medicare plans administered by Medicare itself, Part D is offered by private companies that negotiate prices with the government.
The whistleblower’s complaint states, “CVS Health and its subsidiaries have sold access to the SilverScript Part D formulary, behind closed doors. [Single Source Generic/Do Not Substitute] Drugmakers who deliberately thwart competition from their blockbuster drugs. A formulary is a list of drugs covered by a health plan, negotiated by a pharmacy benefit manager. In this case, that PBM is CVS Caremark, which controls 32% of the market in 2020 and is owned by CVS Health, which also Owns Aetna.
Since 2015, CVS has been involved in a scheme to defraud elderly patients, a practice that continues to this day, the lawsuit alleges.
“Hence, the CVS Health entity” [Single Source Generic/Do Not Substitute] The program aids and abets drugmakers to compete not only based on innovation, but also on their ability to hinder generic competition,” the complaint states.
In fact, CVS Caremark has an agreement with certain drugmakers that prohibits CVS pharmacies from stocking generic versions of two hepatitis C drugs, Called Harvoni and Epclusa. This is just one of many drugs involved in the case. Others include Copaxone, Exelon, Voltaren Gel and several drugmakers including Gilead, Teva, Novartis and others.
Part of the plan involved SilverScript call center employees misleading patients with “outright lies” that brand-name drugs cost less than generics.
An exhibit shows phone records between a CVS customer service provider and a patient trying to obtain a generic form of asthma medication called Advair Diskus. When the patient insisted she wanted a generic version of Diskus, the customer service representative said the only option available was the brand-name version of the drug. At the patient’s request, CVS staff spoke with a member of the Care Exception Review Team to see if the patient was eligible for an exception. CVS staff then suggested that the patient-branded drug cost less than the generic version that the patient sought.
“Typically, when it says to assign a brand exclusively, that means we’re giving you the brand and not the generic because something happened with the generic,” the CVS care provider told patients. A confused patient replies: “What?”
The paramedic said: “If I knew, I promise to tell you. I don’t really know it’s just what she said, but it has a specific note. Even when they take it out at the pharmacy, it literally says the dispensing brand. .”
The patient was puzzled and said she would consult her doctor.
“We intend to vigorously defend this lawsuit and are pleased that the government has chosen not to participate in the lawsuit,” a CVS spokesperson said in an emailed statement.
There are a number of entities that consider the current PBM structure unsustainable and unethical, and emerging pharmacy benefit managers, such as Capital RX, which was founded in 2017, have Summons large PBM operators Like CVS Health.
In addition to its investigation into PBM, the FTC said on June 7 that it would “Increase enforcement efforts to crack down on any illegal bribery and kickback schemes that prevent patients from accessing competitive, low-cost medicines. “
The case is 19-cv-2553 of the District Court of Pennsylvania.
Photo: Alexis Rosenfeld/Getty Images
