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California fines an OptumRx pharmacy for jeopardizing patient health. Is that enough?

The California Board of Pharmacy fined OptumRx, one of the largest pharmacy benefit managers in the U.S., $100,000 for a series of prescribing failures at one of its pharmacies that allegedly jeopardized patient health. The company must also donate $75,000 to a charity that assists underserved communities and its pharmacy was placed on probation for a year.

The infractions, which occurred between 2016 and 2020, involved failures to refill prescriptions promptly, substituting a medicine without written consent, telling a patient his health insurer denied a refill due to cost, and dispensing a generic version of a drug with a costly co-pay when the customer had no co-pay for the brand version, according to a complaint the agency filed last year.

As noted previously, this marked the second time in recent years the state pharmacy board sought to penalize the company for similar violations committed by the facility, which is located in Carlsbad, Calif. A series of citations were issued in 2013 and 2014 for not following dispensing instructions and releasing health information, among other things, according to an earlier complained filed in 2016.

To resolve those accusations made in 2016, OptumRx was publicly censured and ordered to pay a $7,930 fine to cover the costs of the investigation, although the company was allowed to use a payment plan. The company was also ordered to provide healthcare services, such as reduced-cost immunizations, as part of a community service program.

By comparison, the latest penalty is much larger than the earlier settlement, although it still represents a modest amount of money when considering that OptumRx — which is part of UnitedHealth Group and is predominantly known as a pharmacy benefits management unit — generated more than $4.1 billion in profits on revenue of $91.3 billion in 2021.

A spokesperson for the California Board of Pharmacy declined to comment. We should note that the company denied the allegations, according to the settlement document. If the probation period ends without further incident, OptumRx must also reimburse the state more than $140,000 in costs associated with the investigation.

“On one hand, it’s good to see a state board of pharmacy taking this type of action, but on the other, it’s not enough. When there’s a long history of non-compliance and regulators are doing very little, the regulators become part of the problem,” said one industry compliance consultant who asked not to be named, but is familiar with the case. “How many accusations does it take to get a license revoked?”

Another industry expert offered a different view, meanwhile.

“Some settlements appear to look mild and lenient. Yet what leads to a settlement typically stays confidential and behind the scenes,” Nick Oberheiden, an attorney who specializes in health care compliance, told us.

“Pharmacies under investigation can mitigate their exposure by giving the auditor reassurance of structural changes—a commitment, more than a mere promise— that infractions and legal violations won’t occur moving forward. This can occur by replacing management, installing a sophisticated compliance officer, offering enforcement procedures, and strengthening compliance awareness among all team members.”

There is nothing in the settlement document, however, to suggest such an arrangement is in place, although the pharmacist in charge of the location must take an ethics class and attest to his understanding that pharmacists are expected to provide patient consultations. The pharmacist will also have to reimburse the state $2,000 for expenses related to the investigation.


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