Is there illegal discrimination in the prescription drug benefit plan?


Court assesses whether Americans With Disabilities Act allegations are sufficient to initiate legal action

PROBLEM OF THE CASE

When the members of an employee group file a complaint alleging discrimination because of the requirements of their drug plan, are their claims, rooted in the Americans With Disabilities Act (ADA), sufficient for the prosecution to be initiated?

FACTS OF THE CASE

A group of employees from a Western state filed a lawsuit in federal court against 2 groups of defendants. The first set included a national pharmacy chain, a specialty pharmacy it operated, and a pharmacy benefits manager operated by the chain. The second group of defendants included a group of 3 employers, who had contracted with the first group of defendants to provide a drug plan for their employees.

The crux of the complaint, stated by the court early on, was that “the plaintiffs allege that their benefit plans allow them to obtain their HIV / AIDS drugs at favorable ‘on-the-grid’ prices only through la poste ”or at one of the mortar pharmacies operated by the chain.

The court went on to summarize the arguments of the plaintiffs as follows: “In relation to the [nonchain] community pharmacies from which applicants could previously purchase their medications, mail order and [brick-and-mortar] the support options do not offer the same level of privacy, convenience, reliability and service.

Before the creation of the restricted network, patients could obtain their HIV / AIDS drugs at the contractual rate from any pharmacy in the network. The implementation of the new limited-point-of-sale approach meant that employees could obtain these drugs at a reduced rate only from traditional pharmacies or the chain-operated mail-order outlet.

Highlighting these changes, the complainants cited discrimination on the basis of their disability, pointing out certain indignities associated with the new approach and the requirement that many members of the group had to change pharmacy. They identified confidentiality issues when it became apparent that pharmacy staff were not adequately protecting the confidential nature of their medication discussions in front of other people waiting to collect prescriptions, pharmacists who did not know. not patients and their treatment regimens; and problems with mail order services. In addition, if they went to an off-network pharmacy, they would be required to make a more substantial user fee or pay full price for the drug.

The patients / complainants acknowledged that although the new plan in their benefit plan applied more broadly to many employees other than the class members pursuing this lawsuit, there was a disproportionate impact on this group of employees. patients / complainants because of their HIV status. /AIDS. They also recognized that this new approach with its restrictions applied to all drugs designated as “specialty drugs”, not just those intended to treat HIV / AIDS.

The lawsuit was rather complex, as the plaintiffs made 8 separate legal arguments to attack the revised benefit offer, some rooted in federal regulations and laws and others based on provisions of the law of the State. However, a dominant theory underlying the case was an allegation that ADA protections had been violated. All parties from both groups of defendants have petitioned the court to dismiss the lawsuit.

DECISION

The United States District Court judge agreed with the defendants that the case should not go to trial, and the case was dismissed.

THE REASONING OF THE COURT

The court began its written decision by reviewing rulings made on the matter by other courts across the country and stressing that “no consensus has yet emerged on the standard for assessing anti-discrimination claims in the country. ADA “.

He also pointed out that the plaintiffs have “not alleged sufficient statistical evidence to show that the defendants’ program has a” significantly negative or disproportionate impact “on … patients with HIV / AIDS”.

Dissecting the wording of the ADA, the court pointed out that the provisions of the Discrimination Act apply to places of public accommodation. The plaintiffs had attempted to present community pharmacies as the “public accommodation places” at the center of the case.

Nevertheless, the court stressed that the pharmacy branches involved in this case did not prevent the plaintiffs and other members of the group from having access to these pharmacies. Rather, the court found that the subject matter of the lawsuit was the terms or requirements of the insurance plan, which was not covered by the ADA provisions cited by the plaintiffs.

The tribunal also reviewed rulings from federal appeals courts across the country, all of which found that ADA discrimination did not exist when a provision of an insurance plan applied equally to everyone. world under the scheme. If there is no variation in coverage based on disability, there is no discrimination.

The bottom line for the court was that the defendants’ motion to dismiss the case should stand, as the plaintiffs were still allowed to use their home pharmacies even after the implementation of the restricted network approach.


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