In August 2019, OptumRx updated its provider manual to include language concerning a retail pharmacy’s ability to offer free delivery services. OptumRx only permits a retail pharmacy to utilize a W-2 status employee to make deliveries to customers who live within a 100-mile radius of the pharmacy location. OptumRx may permit a waiver for unique or limited single events.
If your pharmacy is using a third-party delivery driver to make local deliveries––even if your patient has authorized your pharmacy to do so in writing––any claims submitted to OptumRx will be subject to recoupment. Notably, even prior to this provider manual update, OptumRx considered the use of third-party delivery drivers by a retail pharmacy to be a violation of the “mailing” prohibition in the provider manual.
Barclay Damon has successfully represented pharmacies across the nation in PBM audits, including on issues related to mail-order and delivery services. Coupled with our attorneys’ experience with PBMs, our knowledge of the rapidly changing legal landscape has allowed us to assist clients with saving tens of thousands in recoupments and chargeback fees as well as avoiding potential termination for contractual violations.
If you have any questions regarding the content in this alert or if your pharmacy is facing a PBM audit or termination, contact Linda Clark, health care controversies team leader, at lclark@barclaydamon.com or Brad Gallagher, counsel, at bgallagher@barclaydamon.com or another member of the firm’s health care controversies team.