Express Scripts delivered unnecessary prescription drugs to military personnel, swindling the federal government and suppliers of billions of dollars, whistleblower claims in False Claims Act lawsuit.
According to a lawsuit filed in California Federal Court in mid-2019 and unsealed Friday. The lawsuit alleges that Express Scripts inflated the cost of drugs to payers and patients through its “pill factory,” which systematically overpriced the military health insurance program for unnecessary drugs from October 2009 to March 2018.
The former pharmacist in charge of the Express Scripts mail-order pharmacy in Tempe, Arizona is seeking damages on behalf of the federal government and the company to stop the alleged fraud. According to court documents, the government has not yet decided whether to intervene.
“Express Scripts hid its behavior from (US Department of Defense) and Tricare, causing the United States to purchase additional pharmaceutical products to replenish prescription drug stocks. Consequently, the United States paid Express Scripts and other providers billions of dollars in excessive vacation fees. and the costs of substitution therapy,” the complaint says.
Express Scripts, which has teamed up with insurance company Cigna Corp. in 2018, did not respond to requests for comment. The law firm representing informant Constantine Cannon declined to comment.
The Express Scripts software was allegedly set to refill 90-day prescriptions on day 60, meaning that each Tricare beneficiary received 73% more pills than prescribed during the year. The lawsuit alleges that the “scheme” indicates a systemic problem among PBMs who over-dispense prescription drugs through automatic refills.
According to complaints filed online in 2016, 2017 and 2018 and included in the lawsuit, several patients complained to the government about Express Scripts, saying the company allegedly sent top-ups too frequently and failed to comply with stop requests. One Tricare beneficiary wrote in May 2016 that she “hates this company and cannot believe the military is forced to use them for maintenance medications. Their actions are negligent at best and criminal at worst.”
The complaint alleges that, since 2003, the Department of Defense has contracted Express Scripts to provide retail, mail order and specialty pharmacy services to approximately 10 million Tricare beneficiaries. The company is paid an administration fee of approximately $17 per prescription. lawsuit claims. The complaint alleges that Express Scripts filled nearly 120 million prescriptions to Tricare beneficiaries in 2017 alone.
The Federal Trade Commission launched an investigation into PBM earlier this month. The agency has required six of the largest PBMs, including Express Scripts, to provide information about their activities as regulators are interested in how vertical integration in the PBM sector affects access and pricing in the prescription drug market.
CVS Caremark from CVS Health, Express Scripts from Cigna and OptumRx from UnitedHealth Group collectively control about 80% of the PBM market, according to the FTC.