From staff reports OKLAHOMA CITY –The Attorney General’s Office has issued a cease-and-desist letter to OptumRx concerning reports that the pharmacy benefit manager attempted to engage in illegal, retroactive reimbursement clawbacks from Oklahoma pharmacies.
The Pharmacy Benefit Manager Compliance and Enforcement Unit received credible information that OptumRx discovered an internal error concerning the Maximum Allowable Cost (MAC) list used from Jan. 1 to July 25 of this year. The wrong list resulted in claims being paid at increased amounts to pharmacies across multiple states, including Oklahoma. OptumRx reportedly attempted to reverse and rerun previously paid claims without notification to pharmacies or their contract agents, which is against Oklahoma law.
OptumRx was sent the warning letter on Thursday by the Attorney General’s Office, demanding OptumRx immediately halt any attempt to recoup payments or retroactively adjust reimbursements for the affected period.
“This error and the extended delay in identifying it is solely attributable to OptumRx. Moreover, this is not the first instance in recent years in which OptumRx has utilized incorrect MAC lists or attempted retroactive recoupments due to its own administrative mistakes,” Drummond wrote in the letter. “This conduct is unacceptable, deceptive, and illegal under Oklahoma law.”
The OAG’s PBM requested “written confirmation, no later than five business days from the date of this letter” [Nov. 20] that OptumRx has:
• implemented a “full halt” on all planned recoupment activity involving Oklahoma pharmacies;
• directed all internal departments and subcontractors to freeze any Oklahoma- related recoupment processes; and
• identified the root cause of the MAC-loading error and taken corrective action to prevent recurrence.
“Failure to comply will result in the initiation of formal enforcement proceedings,” wrote Deputy Attorney General Michael T. Leake Jr. “We expect your full and immediate compliance.”
The Attorney General’s Office warned OptumRx that violations of Oklahoma’s PBM laws may result in penalties up to $10,000 per violation, restitution, and potential suspension or revocation of the company’s authority to operate in Oklahoma.