Humana, Humana Pharmacy Solutions Facing Price-Fixing Class Action

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Citing violations of the Racketeer Influences and Corrupt Organizations Act (RICO), a class action out of Kentucky claims Humana and Humana Pharmacy Solutions engaged in a scheme to artificially inflate prescription copay amounts, which reportedly lead consumers to pay more for prescription drugs than necessary.

Under normal circumstances, insured patients’ copays allow them to pay for a portion of prescribed medications while their health insurance plan covers the rest. The defendants allegedly represented to health plan participants that their copayments were based on some portion of the actual cost of the drug. In reality, however, plan participants were actually paying more than the drug’s total cost, with Humana and Humana Pharmacy Solutions allegedly pocketing the overpayment under the guise of it being a “claw back” recoupment from pharmacies.

“[The defendants] represent to the pharmacies that they are clawing-back the increased copayment amount because consumer overpaid for their prescriptions,” the lawsuit says. “However, [the defendants] never disclose this to plan participants, nor do they reimburse plan participants for their supposed overpayments.”

As for the role of individual pharmacies in this alleged price-fixing scheme, the lawsuit claims many were subject to contractual “gag clauses” requiring pharmacists not to disclose the existence of claw back payments. Pharmacists were essentially instructed not to tell health plan participants that they could pay less for a drug if the purchase is made without applying the pharmacy insurance benefit.