SaveOnSP and PrudentRx

Overview
Pharmacy Benefit Managers (“PBMs”) like Express Scripts and Caremark have partnered with secretive third party companies, such as SaveOnSP and PrudentRx, to siphon off patient copay assistance meant to help patients afford their prescription drugs and to foist thousands of dollars of additional healthcare costs onto patients. Lockridge Grindal Nauen PLLP (“LGN”) has filed suit against these programs for violating federal fraud and insurance laws, and for increasing healthcare costs for targeted patients.

Background

The Affordable Care Act (the “ACA”) provides safeguards against excess healthcare costs for patients in the U.S., including an upper limit on patients’ copay and coinsurance obligations and a maximum that a patient can be forced to pay out-of-pocket each year. Still, prescription drug costs threaten to undermine these protections. PBMs negotiate steep discounts off of drugs’ list prices for the benefit of health plans, but refuse to share those discounts with patients. The result is disproportionately high costs for patients whose need life-saving, but expensive, medications.

Studies lay bare the disastrous effects of PBMs’ efforts to shift healthcare costs to patients: a majority of patients on employer-sponsored health plans report delaying filling prescriptions, rationing medications, or skipping prescribed therapy altogether due to cost. Three quarters of patients cannot afford prescriptions that cost $250 or more out of pocket. To help ensure patients can access necessary and life-saving medications, manufacturers of drugs with high patient costs offer patient assistance programs. These programs cover patients’ out-of-pocket costs up to a set amount. These patient assistance programs, traditionally, have helped reduce the cost burdens of patients with complex and expensive medical conditions.

Recently, PBMs have partnered with companies like SaveOnSP and PrudentRx to evade the ACA’s protections and nullify the relief that patient assistance programs provide. These companies claim to have found a loophole in the ACA: they target expensive medications with the most generous patient assistance programs and designate those drugs “non-essential health benefits,” regardless of how essential the medications may be to a patient’s health. This, they claim, allows health plans to charge copays and coinsurance in excess of the ACA’s limits, and to refuse to count those payments—by patients or patient assistance programs—towards patients’ out-of-pocket limits.

Once retained by a health plan, SaveOnSP and PrudentRx target patients who are on these drugs and increase their out-of-pocket obligations to hundreds, if not thousands of dollars a

month. They then coerce patients to agree to participate in their programs with misleading promises of $0 copays if they participate and the threat of thousands of dollars in out-of-pocket costs if they do not. When patients sign up, these patient assistance raiders drain the maximum amount of funding available from patient assistance programs, and then give that assistance to insurers, not patients.

Targeted patients, meanwhile, lose the benefit of patient assistance. SaveOnSP and PrudentRX refuse to count the large patient assistance payments they collect towards patient’s out-of-pocket obligations. As a result, targeted patients end up having to pay thousands of dollars in additional medical costs during the year that otherwise would have been paid by their insurer after they reached their maximum out-of-pocket limits.

Details of the Investigation

LGN has filed two lawsuits against healthcare industry companies, alleging that those companies steal patient copay assistance funds, violate the ACA, and force patients to incur excess healthcare costs.

Gluesing v. PrudentRx LLC, et al. (filed in federal court in Rhode Island) seeks to hold PrudentRx, LLC and Caremark Rx LLC accountable for a fraudulent scheme to force patients to pay thousands more for their health insurance by depriving patients of the benefit of patient copay assistance.

Gurwitch v. Save On SP, LLC, et al. (filed in federal Court in the Northern District of New York) seeks to hold Save On SP LLC; Express Scripts, Inc.; and Accredo Health Services, Inc. accountable for a similar scheme.

Contact
If you have been impacted by programs like SaveOnSP or PrudentRx and would like to get involved, please submit your information below or reach out to Brian Clark or Kristie LaSalle.

Documents
Complaint – Gluesing v. PrudentRx LLC, et al.
Complaint – Gurwitch v. Save On SP, LLC, et al