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: PayerMatrix is required to respond within 21 days of receiving the complaint.
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 May 28, 2023 by Aimed Alliance
