The Tamoxifen Co-Pay Report Form
Should you be part of this class action?
Tamoxifen Court
Order
Defendents' Motions to Dismiss Denied
Her doctor said tamoxifen was generic. Her insurance company said the drug was brand name. And since the insurance company was paying most of the cost, the insurance company's claim won out. So Evelyn Morse, a breast cancer patient, paid the price.
After all, what else could she do? PCS, the drug management company that processes prescriptions for her insurance carrier, Banker's Life & Casualty Company, demanded that the pharmacy charge her the co-pay or she couldn't have her medicine.
So for three years Mrs. Morse paid the higher brand name co-pays because, as far as she knew, she had no choice. Then she talked with her grandson, an attorney. He said what PCS was doing was illegal.
This small beginning in the southeastern Massachusetts coastal city of New Bedford has already turned into a big can of worms for insurance companies. United States District Court Judge Joan P. Gottschall has certified a nationwide class action lawsuit against both companies to include
"All persons insured by a policy of insurance with Bankers Life & Casualty Company who obtained tamoxifen prescriptions from pharmacies that are part of the PCS network and who were charged for tamoxifen as though it is a brand name drug."
In her lawsuit, filed in Illinois where Bankers Life has its headquarters, Mrs. Morse claims: breach of contract, breach of the duty of good faith and fair dealing, violation of the Illinois Uniform Deceptive Trade Practices Act, violation of the Illinois Consumer Fraud and Deceptive Business Practices Act, civil conspiracy, and violation of the Racketeer Influenced and Corrupt Organizations (RICO) Act.
This appears to be only the tip of the iceberg because the market for tamoxifen is huge. In 1999, tamoxifen sales totaled over $328,000,000. Plus, 180,000 women develop new cases of breast cancer each year.
Now, the majority of HMOs have moved to a three-tiered co-payment system based on drug classification, so mis-classifying this one drug could earn insurance companies millions of dollars each year in overpayments on co-pays. For example, many insurance companies have tamoxifen mis-classified as a “preferred brand name drug” requiring a $10 co-payment increase over a generic classification. With such a structure, every time a consumer buys tamoxifen, they pay $10 more than they should. Over the course of a year, this money adds up.
Mrs. Morse bought what is commonly called a Medigap insurance policy from Bankers Life to cover prescription drugs because Medicare does not. The policy promises to pay 100 percent of the cost of prescription drugs that are generic and 80 percent of the cost of brand name drugs.