Federal officials late Monday said they will join a pair of whistleblower suits against Medco Health Solutions, in which a physician and two former company employees charge the pharmacy benefits manager with manipulating prescriptions to defraud federally funded health plans.
Medco denies all allegations.
The decision is the latest move in an investigation into the PBM industry that the U.S. attorney's office in Philadelphia has been conducting for five years.
"The kind of conduct alleged in the complaints threatens not only the integrity of the system as a whole but also the well being of the very patients it is designed to benefit," U.S. Attorney Patrick Meehan says in a statement.
"Getting the proper medication in the hands of patients as quickly and efficiently as possible should be the mission of any pharmacy benefit manager. However, these allegations suggest that, somewhere along the line, the focus became the profit instead of the patient," Meehan says.
Meehan notified the U.S. District Court in Philadelphia that his office will file a civil complaint against Franklin Lakes, N.J.-based Medco by Sept.30.
However, Medco, in a statement to the media, says, "We would note that the U.S. attorney stated an intention to intervene; no lawsuit has been filed by the U.S. attorney."
Meehan says the forthcoming federal suit will incorporate charges brought in a February 2000 qui tam suit by New Jersey physician Joseph Piacentile, M.D., and a separate case initiated in 1999 by pharmacists George Bradford Hunt of Las Vegas and Walter Gauger, who now resides in Plantation, Fla. The two pharmacists worked at a Medco mail-order pharmacy in Las Vegas until 1998.
The states of Florida, California, Illinois, Tennessee, Texas, Michigan, Louisiana, Nevada, Massachusetts and Virginia and the District of Columbia also are parties of the Hunt-Gauger suit against the company formerly known as Merck-Medco Managed Care. The PBM is a wholly owned subsidiary of pharmaceutical manufacturer Merck & Co.
Meehan says the U.S. will limit its intervention to charges that Medco submitted and attempted to cover up false claims to federal payers, including Medicare, Tricare and the Federal Employees Health Benefits Program, which is administered in part by Blue Cross Blue Shield licensees.
The whistleblowers charge Medco with:
- Canceling, deleting and destroying patients' mail-order prescriptions on days of heavy prescription volume so the company could avoid penalties for being late in filling and mailing prescriptions.
- Charging full price for filling prescriptions with fewer pills than ordered.
- Changing prescriptions based upon false or misleading information provided to physicians.
- Lying to the Blue Cross Blue Shield Association about compliance with rules in a federal contract requiring that prescriptions be mailed within five days of receipt.
- Inducing physicians to authorize costlier medications under the guise of reducing prescription costs for the health plan.
- Favoring Merck drugs over other products, even when the Merck drugs were more expensive.
- Violating state laws requiring drug utilization review by a pharmacist and consultation with the treating physician where there is a potential for drug-drug interactions.
- Fabricating records of calls by pharmacists to physicians.
- Failing to call physicians for clarification when the prescription received by the pharmacist is ambiguous.
In the Medco statement in response to the intervention, the PBM says, "We are prepared to prove that the allegations in the whistleblower complaints are absolutely untrue--or reflect past issues that were identified and corrected. We believe the issues that have been corrected did not compromise the quality of patient care."