AbbVie v. Payer Matrix, LLC
Brief summary: AbbVie, a pharmaceutical company, filed a lawsuit against Payer Matrix, an alternative funding program, alleging that the company engaged in a “fraudulent scheme” that exploits AbbVie’s charitable assistance program.
Background: Alternative funding programs partner with health plans to manage the plan’s specialty medications benefits. Under these programs, plan enrollees are required to enroll in the alternative funding program to access their specialty medication or be responsible for 100 percent copay or coinsurance that will not count towards their annual cost-sharing requirements. Once enrolled in the alternative funding program, the alternative funding program collects personal information from the plan enrollee to determine if they are eligible to receive their specialty medication from (1) a manufacturer copay assistance program; (2) a charitable assistance program; or (3) an international importation program.
Typically, to be eligible for a charitable assistance program the individual must be either uninsured or underinsured. As such, to ensure plan enrollee’s eligibility for a charitable assistance program the health plan will automatically deny coverage for the specialty medication to allow the alternative funding program to apply to the charitable assistance program on behalf of the plan beneficiary. If the plan enrollee is not eligible for the charitable assistance program, or an alternative source, the specialty medication will be sent back to the plan and covered as a regular pharmacy benefit.
Overview: On May 5, 2023, AbbVie filed a lawsuit in U.S. District Court for the Northern District of Illinois against Payer Matrix. AbbVie’s complaint alleges that the alternative funding program “operates a fraudulent and deceptive scheme to enrich itself” by exploiting AbbVie’s charitable assistance program – which is intended to provide free drugs to financially qualifying uninsured and underinsured patients.
The complaint alleges that Payer Matrix knowingly “maneuver[ed]ineligible patients into AbbVie’s [charitable assistance program],” through acts of fraud and deceit, including by allegedly lying to doctors and altering patient documents to conceal their involvement in the charitable assistance program application. AbbVie alleges Payer Matrix had to disguise its involvement as AbbVie’s program terms exclude patients who are enrolled in alternative funding programs. AbbVie alleges that as a result of this scheme, Payer Matrix has profited millions by charging employers for “cost-avoidance fees” for each medication distribution patients received for free, costing AbbVie more than $30 million in 2021 and 2022.
The complaint requests that the Court issue an injunction to prohibit Payer Matrix from applying its alternative funding program to AbbVie therapies, and award economic and punitive damages.
Read the complaint here.
Current Status: On April 14, 2025, the court denied AbbVie’s motion for a preliminary injunction, finding that AbbVie failed to present sufficient evidence that Payer Matrix’s conduct is ongoing or likely to recur, and did not meet its burden to demonstrate that it would suffer irreparable harm absent injunctive relief.
On April 22, 2025, Payer Matrix filed a motion to dismiss AbbVie’s First Amended Complaint for failure to state a claim. On May 22, AbbVie filed an opposition to the motion. Then, on May 29, the parties submitted a joint status report: AbbVie argued that general discovery should proceed, while Payer Matrix contended that the Court’s existing order staying general discovery should remain in effect until the pending motion to dismiss is resolved.
Impact: A court order issuing Payer Matrix to cease their deceptive scheme would prohibit Payer Matrix from continuing its alternative funding program for AbbVie manufactured treatments until the Court decides the case on its merits. If AbbVie prevails this could ensure that patients are not forced to enroll in alternative funding programs to access their medications and protect the sustainability of charitable assistance programs for underinsured and uninsured patients.
Last Updated on June 5, 2025 by Aimed Alliance
