Express Scripts delivered unnecessary prescription drugs to military personnel, bilking the federal government and vendors out of billions of dollars, a whistleblower alleges in a False Claims Act lawsuit.
The St. Louis-based pharmacy benefit manager allegedly enrolled as many Tricare beneficiaries as possible in automatic delivery, which was set up to provide an extra nine-month supply of drugs over the course of a year, according to a qui tam lawsuit filed in a California federal court in mid-2019 and unsealed Friday. Express Scripts inflated drug costs for payers and patients through its "refill pill mill" that systematically overcharged the military's health insurance program for unnecessary medication from October 2009 to March 2018, the suit alleges.
The former pharmacist in charge of Express Scripts' mail order pharmacy in Tempe, Arizona, seeks damages on behalf of the federal government and for the company to stop its alleged fraud. The government hasn't decided whether to intervene, according to court filings.
"Express Scripts hid its conduct from (the U.S. Defense Department) and Tricare, causing the United States to purchase additional pharmaceutical products to replenish its prescription drug supply. Consequently, the United States paid Express Scripts and other vendors billions of dollars in excessive dispensing fees and drug-replacement costs," the complaint alleges.
Express Scripts, which merged with the insurer Cigna Corp. in 2018, did not reply to requests for comment. The law firm representing the whistleblower, Constantine Cannon, declined to comment.
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 over the course of a year. The "scheme" is indicative of a systemic problem among PBMs that over-dispense prescription drugs through automatic refills, the suit alleges.
Multiple patients complained about Express Scripts to the government, saying the company allegedly sent refills too often and would not honor requests to stop, according to complaints submitted online in 2016, 2017 and 2018 and included in the suit. One Tricare beneficiary wrote in May 2016 that she "hates this company and cannot believe that military members are forced to use them for maintenance medications. Their actions are at best negligent and at worst criminal."
The Defense Department has contracted with Express Scripts since 2003 to provide retail, mail-order and specialty pharmacy services to approximately 10 million Tricare beneficiaries, the complaint alleges. The company is paid an administrative fee of approximately $17 for each prescription dispensed, the lawsuit alleges. In 2017 alone, Express Scripts dispensed nearly 120 million prescriptions to Tricare beneficiaries, the complaint alleges
The Federal Trade Commission initiated an investigation into PBMs earlier this month. The agency required the six largest PBMs, including Express Scripts, to provide information about their activities as regulators inquire about how vertical integration in the PBM sector affects access and pricing in the prescription drug market.
CVS Health's CVS Caremark, Cigna's Express Scripts and UnitedHealth Group's OptumRx collectively control about 80% of the PBM market, the FTC said.
