The Tamoxifen Co-Pay Report Form
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Tamoxifen Court
Order
Defendents' Motions to Dismiss Denied
Before filling the prescription, the pharmacy accesses PCS' system and determines whether PCS will pay 100 percent of the cost or whether the policyholder must co-pay 20 percent at the time of delivery. Under Mrs. Morse's policy, in the case of generic drugs, the pharmacy releases them to the patient with no exchange of money because it will receive 100 percent from PCS. In the case of brand name drugs, the pharmacy must collect 20 percent from the customer because it will receive only 80 percent from PCS.
Mrs. Morse enrolled in the PCS system by Bankers Life in 1997. Since then, she has been charged a 20 percent co-pay for each tamoxifen prescription. To avoid these co-payments, Mrs. Morse asked her physician to prescribe a generic drug rather than tamoxifen. Her physician told her that tamoxifen is a generic drug. She contacted Bankers Life, which explained that PCS classified tamoxifen as a brand name drug. Further, Bankers Life told Mrs. Morse that she should continue to pay the 20 percent co-pay and, if she then contacted Bankers Life, she could be reimbursed the 20% she overpaid.
In the Court's ruling, Judge Gottschall wrote:
"Presumably, numerous Bankers Life policyholders other than Morse are prescribed tamoxifen. It defies common sense to believe that all of them, having been required to pay 20% which Bankers Life was contractually obligated to provide, realize that they have gotten less than they bargained for and have sought reimbursement. If Bankers Life had to respond to all this correspondence and issue all those monthly checks for $18, it can be presumed that dealing with PCS' system's misclassification would become so expensive that something would be done about it. It is far more likely that some very large number of the Bankers Life policyholders needing tamoxifen are paying 20% of its cost out of ignorance that Bankers Life is contractually obligated to pay that 20% for them, and that Bankers Life is realizing considerable savings from PCS' misclassification."
For years, cancer patients have had to pay higher co-pays because of this mis-classification. Drug management companies tell breast cancer patients they can either compromise their health or pay higher co-pays. It's the ultimate in strong arm tactics.
In the same ruling, the Court denied the defendants' attempts to dismiss Mrs. Morse's RICO claims, noting:
"The misclassification of a commonly prescribed drug, and the decision of Bankers Life to pay the one complaining policyholder rather than take steps to correct the misclassification, strongly suggests that there are a large number of patients and many predicate acts… [S]ince Bankers Life chooses to employ PCS to administer its drug benefit program, Bankers Life's response to Morse's complaint — that nothing would be done to correct the situation — suggests at the very least Bankers Life's knowing participation in the operation and management of an enterprise which results in its receipt of large amounts of money to which it is not entitled."
Other insurers presumably profit from the mis-classification of tamoxifen because prescription management companies, like PCS, manage drugs for many large insurers. We are starting to make a list of insurance companies that are mis-classifying the drug in an effort to force those insurers to change the practice.
We'd like to hear from patients who think they might have been overcharged for co-pays on tamoxifen, regardless of which insurance company they're with.
If you believe you're one of those people, please complete the “Tamoxifen Co-Pay Report Form,”
or call toll free 1-877-892-5620. There's no cost or obligation.