Zurik: United/Optum defends prescription 'overpayment program'

Are YOU paying too much for your medications?
Published: May. 9, 2016 at 7:06 PM CDT|Updated: May. 9, 2016 at 11:07 PM CDT
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NEW ORLEANS (WVUE) - A series of emails we received from a subsidiary of United Healthcare raises more serious questions about the country's largest health carrier. Our investigation last week showed United says its charging customers a copay for some drugs. But in actuality, that copay is a "you-pay" - United charges more than the cost of the drug.

"The absurdity is beyond belief," says a pharmacist who spoke to us on condition of anonymity.

This pharmacist is among the sources providing FOX 8 with example after example of copays that are higher than the actual cost of the drug.  Pharmacists call this a "clawback" - healthcare providers clawing back money from pharmacies and customers.

In a statement to FOX 8 News, United Healthcare – through its subsidiary, Optum - admitted to the practice, writing:

OptumRx's Pharmacy Reimbursement Overpayment program helps ensure the millions of people we serve have affordable access to the drugs they need.

"OptumRx causes the overpayment to happen and they get the money," our source tells us.

We emailed Optum back and said we "Googled the program name" but and didn't see "any documentation or reference to it on the Internet."

An Optum spokesperson responded, "I'm not sure there's an official name."

Remember: They referenced the program in the statement and even capitalized the first letter in each word, "OptumRx's Pharmacy Reimbursement Overpayment program" - usually an indication it's a proper noun, a real thing.

In that statement, Optum told us the Pharmacy Reimbursement Overpayment program recoups overpayments that pharmacies receive for prescription drugs:

Those recouped overpayments are returned to the health plan to reduce overall health plan costs.

But our local pharmacist says the statement is misleading.  He tells us Optum sets the cost of the drug and the amount of payment.

"We collect that overpayment right there because they told us to take it," he says. "But we have to send it right back to them."

United Healthcare, through its pharmacy benefit manager Optum, essentially is charging people a premium on drugs - people are unknowingly paying more for a drug than it's actually worth.

In our email exchange, Optum stressed:

A consumer doesn't pay any more with this program than they would without it.

But documents and information provided by pharmacists show that's simply not true.

A case in point: Optum required a pharmacist to charge someone a $50 copay for the acne and birth control pill Sprintec. Optum noted the actual cost of the pill, $11.65, and made the pharmacy send the difference back to them, Optum or United.  According to the online pharmacy search website LowestMed.com, the same consumer could have bought this drug without using insurance, at both independent and chain pharmacies in the area, for $13.66.  They could have saved about $36.

Still, in that email exchange, Optum reiterated:

To be clear: this program ensures the customer pays the lowest amount possible within their plan.

That didn't appear to happen in another example, either.  Optum had a pharmacist collect a $15 copay for an anxiety drug.  But if someone had come into our source's pharmacy and paid for that drug without insurance, the pharmacist says, "We would have charged $9.64, just cash off the street… They would have saved, well… $5.36."

United and Optum label this a copay, right on the paperwork. But the company pays nothing toward the cost of these drugs.

"It's not a copay," the source insists. "Copay, by definition, means we pay some, you pay some. [But] this is strictly 'I am paying the pharmacy for the meds and I'm giving you money for the privilege of saying I have insurance.'"

Optum sent us one more email, noting yet again:

There is no difference in cost to consumers as a result of this pharmacy benefit program.

Yet pharmacists gave us document after document that show United/Optum collecting more money in a copay than the drug is actually worth.  That's customer after customer after customer who could have paid cash, paid without insurance, and saved money. You

Like many pharmacists, our source has a contract with Optum. When we ask him what might happen If Optum identified him as a source for our investigation he told us, "They would come after me. They would want to kick me out of network because we're not supposed to disclose anything."

The source says United and Optum don't want pharmacists telling the truth "because people would be outraged if they knew that they were actually paying an extra premium, every time they got a prescription filled."

We requested an on-camera interview with Optum; they have yet to agree to that.   We also told them we found many examples of medication that would have been cheaper for customers to buy off insurance, and asked, "How is there no difference in cost to the consumer?"

We wanted to know why Optum isn't telling customers, in some cases, that there is no copay - only one person is paying. We also wanted documentation on this overpayment program, and documents that inform customers they may be overpaying for drugs. And we wanted proof that these overpayments actually reduced overall health plan costs - some other companies don't have such a program, after all, and don't overcharge for drugs.

Optum never responded.

"I can tell you the reason why they didn't want to respond," our pharmacist says, "because if they respond, they're expected to respond truthfully.  And that's total nonsense."

We did get one more email from Optum last week, clarifying their statement.  After we peppered them with questions, the program used as a proper noun changed - capitalized letters changed to lowercase - and Optum eliminated the word overpayment:

OptumRx's pharmacy reimbursement program helps ensure the millions of people we serve have affordable access to the drugs they need by ensuring they pay the lowest price available to them for prescription drugs.

We gave United and Optum a deadline of close of business Friday to respond to our questions. We never heard back. A spokesperson did email us at 4:30 Monday; he said, at this time, the company would not provide any on-camera interviews. He also did not answer any of our questions, but did say he may be able to provide an expert to speak on background later this week.

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