On November 22, 2019, Cohen Milstein, serving as Special Counsel to Ohio Attorney General Dave Yost, filed an amended complaint asserting breach of contract claims against OptumRx Administrative Services, LLC (“OptumRx”), a pharmacy benefit manager, on behalf of the Ohio Bureau of Workers Compensation (“BWC”), the Ohio Department of Administrative Services, and the State of Ohio, in the Court of Common Pleas, Franklin County, Ohio.   

OptumRx answered the amended complaint, and discovery is underway.

Case Background

Plaintiffs bring this lawsuit for breach of contract and seek to recover damages from OptumRx, which has been the pharmacy benefit manager responsible for administering pharmacy services for BWC’s workers’ compensation insurance plan from 2009 through 2018 to Ohio workers who have been injured at work.

Specifically, Plaintiffs allege that for the duration of BWC’s contract with OptumRx, OptumRx breached the contractual pricing terms, which required OptumRx to adjudicate and reimburse pharmacy claims for multi-source generic medications at the lowest of four available pricing options: (1) the Maximum Allowable Cost (“MAC”), an amount which is set by OptumRx; (2) the Federal Upper Limit, a price set by the Centers for Medicare and Medicaid Services; (3) the Average Wholesale Price (“AWP”), which is a common drug-pricing benchmark, with a nine percent discount; or (4) the pharmacy provider’s “usual and customary charge” for the drug, which is typically the cash price a patient would pay for a drug without insurance.

Plaintiffs also allege that OptumRx breached an additional contractual pricing term that became effective on November 1, 2016. This pricing term required OptumRx to manage BWC’s MAC pricing to achieve a “MAC Effective Rate” of the drugs’ AWP discounted by 74 percent, at a minimum.

Plaintiffs further allege that OptumRx failed to meet its obligation under the contract by causing unreasonable delays when adding new drugs to the MAC list and failing to update pricing to account for decreases in generic drug costs, resulting in additional direct monetary damages to Plaintiffs.

Finally, Plaintiffs allege that OptumRx’s contractual breaches were committed in bad faith and were inconsistent with the Plaintiffs’ justified expectations regarding OptumRx’s performance under the BWC Contract, and that these actions breached the duty of good faith and fair dealing implied in every contract under Ohio law.

Ohio Bureau of Workers’ Compensation, et al. v. OptumRx Administrative Services, LLC, Case No. 19CV002263, Court of Common Pleas, Franklin County, Ohio