AIDS Healthcare Foundation sues Express Scripts over Medicare 'clawbacks'

The AIDS Healthcare Foundation has filed suit against Express Scripts over "clawbacks" from the organization's pharmacies.

In the lawsuit, filed in Missouri federal court, AHF alleges that the pharmacy benefit manager manipulates Medicare star ratings to ensure participating pharmacies get unfairly low scores. Thanks to these scores, the PBM then claws back Medicare benefits from pharmacies to pad its bottom line.

Express Scripts, a subsidiary of Cigna, often initiates these clawbacks months or years after the fact, AHF said in the suit. The PBM's size as one of the largest in the country gives it significant power over smaller community and specialty pharmacies like AHF.

“AHF brought this civil action to recover many millions of dollars taken by Express Scripts, purportedly pursuant to unconscionable contracts with AHF yet in violation of those very contracts and the covenant of good faith and fair dealing implied in those contracts, among other violations of AHF’s rights,” said Andrew Kim, AHF’s lead counsel on the matter, in a statement.

Cigna generally does not comment on pending litigation.

In the suit, AHF alleges 14 different violations across nine states where it operates pharmacies. For instance, the organization asserts that the PBM used unfair or deceptive business practices in California, Florida, Louisiana, New York and Washington.

The lawsuit also claims that Express Scripts violated "any willing provider" laws in Georgia, Illinois, Louisiana, Mississippi and South Carolina.

AHF is seeking a jury trial.