Another OptumRX Lawsuit, More Pharm-To-Table, & Medicare Clawbacks

Hey all, 

Happy Monday! UnitedHealth's problems keep piling up. There don't seem to be any ready solutions. Their PBM is under increased scrutiny and their Medicare Advantage division is facing increased costs. Take those two growth levers away and what's left? A very large company with a very unclear path forward.

Enjoy the rundown! 

Jacob Brody (Co-Founder & CEO, ZorroRX)

(Star Tribune) Union Sues Optum Rx Over Weight-Loss Drug Payments

A Minneapolis-based construction union health plan is suing Optum Rx, alleging it improperly approved over $4.3 million in claims for weight-loss drugs like Wegovy and Zepbound that weren’t covered under the plan’s terms. The lawsuit adds to mounting criticism of pharmacy benefit managers (PBMs), who are accused of opaque billing practices that prioritize profits over transparency and patient care. But let’s be honest—compared to federal investigations and DOJ scrutiny, this probably feels like a stubbed toe for Optum Rx. Full Article.

(Reuters) Bristol Myers, Pfizer to Sell Eliquis Directly to U.S. Patients 

Bristol Myers Squibb and Pfizer will begin selling Eliquis directly to uninsured and underinsured U.S. patients at a 43% discount, dropping the monthly price from $606 to $346. While the move bypasses insurers and middlemen, experts note the cost is still far above international prices and may remain out of reach for many patients. It’s another example of “pharm-to-table” pricing—technically more affordable, but still not something most people can actually stomach. Full Article

(STAT News) Trump Administration’s Medicare Clawback Plan

The Trump administration is accelerating its plan to recoup $7.8 billion in Medicare payments from hospitals related to drug pricing overpayments, aiming to complete the clawback by 2031 instead of 2041, potentially reigniting legal challenges from hospital groups. This move stems from the Supreme Court's 2022 ruling that previous Medicare drug payment cuts were illegal, prompting the government to both repay hospitals and now retrieve overpaid funds used to balance the budget—sparking criticism from hospital lobbyists who argue the approach is punitive and unlawful. Additionally, the administration plans to revive drug acquisition cost surveys that could justify future cuts to hospital drug reimbursements. Full Article