The Jacobs Law Group (JLG) Wins Court Decision That It Is a Breach of Contract for OptumRx to Create and Use Multiple MAC Prices to Reimburse Pharmacies Different Amounts When Dispensing the Same Drug on the Same Date to Members of The Same Health Insurance Plan

In a significant decision that may change the PBM world and which could be a major step toward saving local independent pharmacies, JLG lawyers led by Mark Cuker, Esq. won a tremendous ruling: that within a single health insurance plan, Optum cannot reimburse an independent pharmacy using MAC prices that are lower than the MAC price used to reimburse a retail chain pharmacy or mail order pharmacy for a particular drug dispensed on the same date without breaching its own contracts.

This means that JLG’s asserted claim for relief against Optum for reimbursing large mail order  pharmacies (i.e., Optum’s own mail order pharmacy) and retail pharmacy chains (such as CVS and Walgreen) at MAC prices which were higher than the MAC prices Optum reimbursed independent pharmacies will now proceed in court. See Robert D. Mabe d/b/a Ashville Apothecary and Circleville Apothecary et-al. v. Optum, RX, Successor by Merger to Catamaran Corp.  Civil Action No. 3:17-1102 (Decision filed May 28, 2021; 2021 WL 2186105). The independent pharmacies have asked for a jury trial.

In Robert D. Mabe, JLG represents 430 pharmacies who claim they were reimbursed by Optum at lower MAC prices than those Optum used to reimburse large retail chain and mail order pharmacies.

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