The findings of a recent audit of a major company that manages prescription benefits revealed it may have violated Mississippi law.

The review of Minnesota-based Optum’s business practices by the Mississippi Board of Pharmacy indicated that the company paid independent pharmacies in Mississippi rates lower than chains and Optum-affiliated pharmacies for the same prescription drugs. 

The audit uncovered over 75,000 instances in which Optum-affiliated pharmacies’ lowest payments for a prescription drug were higher than at unaffiliated pharmacies in one year, including chain and independent drug stores. 

Mississippi state law prohibits pharmacy benefit managers from reimbursing their affiliate pharmacies, or ones they own, at higher rates than non-affiliate pharmacies for the same services. 

In some cases, patients footed the bill: consumers were almost twice as likely to pay the full cost of a prescription drug claim without contributions from their insurance plan at independent pharmacies than at affiliated pharmacies. 

The Board of Pharmacy will hold an administrative hearing based on the alleged violations of Mississippi law on Dec. 19. Board staff declined to answer questions about the audit or its findings. 

“I think this proves that we need to have more transparency, we need to have more PBM reform in Mississippi and across the country and even on a federal level,” said Robert Dozier, the executive director of the Mississippi Independent Pharmacy Association, an organization that advocates for 180 pharmacy members.

Optum declined to answer specific questions about the audit. The company has identified errors in the audit’s findings and methodology and submitted them to the Board of Pharmacy, said Isaac Sorenson, a spokesperson for Optum. 

“The pharmacy – and local pharmacists – play a vital role in supporting people’s health and we are committed to paying them fairly,” he said. “…For pharmacies in rural and underserved communities, Optum Rx is deepening its commitment to support their role by launching new programs, expanding existing initiatives and launching a new pharmacy network option for customers.” 

He said the new pharmacy network option will provide pharmacies with increased reimbursements. Generic drugs will be reimbursed at 5% higher rates and brand name drugs at .2% higher rates. 

Optum is owned by health care behemoth UnitedHealth Group Inc., the U.S.’ most profitable health care company and the owner of the nation’s largest health insurance company, UnitedHealthcare. In 2023, the company reaped $32.4 billion in earnings. 

Pharmacy benefit managers are private companies that act as middlemen between pharmacies, drug manufacturers and insurers. They process prescription drug claims, negotiate pricing and conditions for access to drugs and manage retail pharmacy networks. 

Optum is one of the largest three pharmacy benefit managers in the U.S., which together account for 79% of prescription drug claims nationwide. 

The results of the audit echoed some of the conclusions of a Federal Trade Commission report published in July: large pharmacy benefit managers pay their own, affiliated pharmacies significantly more than other pharmacies and set reimbursement rates at untenably low levels for independent drug stores, or retail pharmacies not owned by a publicly traded company or owned by a large chain, said the report. 

Mississippi Today reported last month that many Mississippi independent pharmacists fear they may be forced to close their businesses due to low reimbursement rates from pharmacy benefit managers. 

Pharmacy benefit managers have an incentive to steer customers towards their affiliate pharmacies and compensate them at higher rates, which can disadvantage unaffiliated pharmacies and lead to higher drug costs, said the Federal Trade Commission. 

Optum’s affiliate pharmacies include Optum Home Delivery Pharmacy and Optum Specialty Pharmacy. 

The audit revealed that Optum uses 49 different maximum cost lists, or schedules created by pharmacy benefit managers that determine the highest price they will pay pharmacies for generic drugs. Maximum cost lists are proprietary and confidential, even to the pharmacies that are reimbursed based on the lists, and change continuously.

“I think that’s 48 too many,” said Dozier. “There should only be one MAC list.”

Fifteen are used exclusively at independent pharmacies and 22 are used solely at chain pharmacies. 

An analysis of the maximum allowable cost lists showed that independent pharmacies were reimbursed at rates 74% lower than chain pharmacies on average.

An analysis of a generic drug used to treat bacterial infections yielded a payment to an Optum-affiliated pharmacy that was eight times higher than the lowest-paid independent pharmacy on the same day. Chain and affiliate pharmacies were paid over 20 times as much as independent pharmacies for a generic drug used to treat stomach and esophagus problems.

Pharmacies’ attempts to contest low reimbursement rates were often unsuccessful, showed the audit. 

Ninety-eight percent of pharmacy appeals were denied, most commonly because they did not include information about how much the pharmacy paid to acquire the medication from a wholesaler. 

Mississippi law prohibits pharmacy benefit managers from reimbursing pharmacies at rates below their cost to acquire the drug, even when using a maximum allowable cost list. But the audit revealed over 400 times that Optum denied pharmacies’ appeals on those grounds, saying that the maximum cost list was accurate. 

The audit, which studied Optum in 2022, was the first commissioned by the Mississippi Board of Pharmacy after revisions to state law in 2020 gave it more regulatory authority over pharmacy benefit managers. 

It took the board several years to hire staff to enact the law and receive approval to increase its budget due to the high costs of audits, the board’s executive director Susan McCoy told lawmakers at the House Select Committee on Prescription Drugs Aug. 21 at the Capitol.

The board also has pending administrative proceedings with the other largest pharmacy benefit managers in the country, Express Scripts and CVS Caremark. Neither is the result of an audit. Both hearings are scheduled for Nov. 21. 

Optum has already faced scrutiny for its business practices in Mississippi. In August, Attorney General Lynn Fitch filed a lawsuit alleging that Optum and several other pharmacy benefit managers stoked the opioid epidemic by plotting with manufacturers to increase sales of the addictive drugs and boost their profits. The suit also named Evernorth Health and Express Scripts, along with the companies’ subsidiaries. 

You may be surprised that the largest, freshwater fish in North America may be swimming in the Mississippi River under the I-20/Hwy. 80 bridges at Vicksburg as you are reading this. The Alligator Gar is a monster-sized fish, capable of exceeding 300 pounds described as a beautifully grotesque fish in Mark Spitzer’s book “Beautifully Grotesque Fish of the American West.” Many scientists refer to Alligator Gar as a “living fossil” because they have remained relatively unchanged for over a 100 million years.  The broad snout and double row of upper teeth resemble an alligator, hence their name.

During most of the 1900’s, Alligator Gar were considered a “trash fish,” essentially useless, and possibly damaging to the environment, similar to carp. Because of their size and voracious appetites, fisherman assumed they were eating their prized sportfish, like Largemouth Bass, crappie, and Bluegill. They were targeted for elimination by state wildlife agencies and the numbers of Alligator Gar quickly diminished. More recently, scientific studies have shown that this species primarily eats forage fish, like Gizzard Shad, and also occasionally enjoys an unwary duck or a feisty beaver swimming along the surface.

Modern ecology has warned us not to eliminate apex predators from the environment without unintended consequences. Maybe that is one reason invasive carp continue to spread throughout the Mississippi River basin – there are no natural predators large enough to consume that many carp to make a difference in their growing numbers, except maybe the Alligator Gar. Now, state and federal agencies are stocking these fish back into their native ranges and numbers are steadily increasing.

Who wouldn’t want to catch a 300-pound fish? Actually, the Mississippi state rod and reel record is 215 pounds, bow and arrow record is 234 pounds, but the largest Alligator Gar caught in the state was in Lake Chotard in 2011, right upstream from Vicksburg, weighing 327 pounds!

Not only are Alligator Gar fun to catch, many people enjoy eating them like Cajun gar balls, usually fried, and I have heard that the backstrap is delicious. A word of caution – do not eat the greenish eggs for they are toxic to humans. But there are other uses. For those of you who live close to the Mississippi River during the spring, I recently read that gar oil was used by the people of Arkansas as a repellant for those pesky buffalo gnats coming from the river to bite you and leave week-long sores on your skin after they consume your blood to nourish their developing eggs. On a lighter note, the serrated ganoid scales that cover the fish, resembling a coat of armor, are used to fashion jewelry such as necklaces.

Folks sometimes ask if it’s safe to swim in the Mississippi River. During the summer, the Louisiana shore across from Vicksburg often resembles the Mississippi Gulf coast during spring break with boats tied together, umbrellas lining the beach, and people wading, swimming, and riding their jet-powered water bikes. The Mississippi River may have more sandy beaches than all of the beaches in Florida combined.

So other than an occasional bull shark (that’s another story), I am not aware of any other fish in the Mississippi River that will intentionally attack a human including Alligator Gar. In fact, Jeremy Wade of “River Monsters” concluded in one of his shows that there has never been any evidence that Alligator Gar attacked or killed humans.

Alligator Gar are a keystone species roaming around in America’s greatest river providing recreational fishing opportunities, food for humans, and control of invasive species. Maybe you will encounter one of these “beautifully grotesque” fish one day.

Jack Killgore, Ph.D., is a resident of Vicksburg. Prior to retirement, he was a long-time employee of the U.S. Army Corps of Engineers (ERDC). He also serves as an enrichment speaker on the Viking Mississippi and teaches river science courses at Tulane University. He can be reached at kjkillgore@gmail.com.

Read his first column, “How Deep is the Mississippi River?,“ by clicking here.

JACKSON, Miss.—Incumbent U.S. Sen. Roger Wicker, a Mississippi Republican who supports legislation that could ban abortion from the moment of conception, easily won reelection on Tuesday night and will serve another six-year term representing Mississippi in Congress. He defeated Democratic candidate Ty Pinkins.

Wicker told the Mississippi Free Press he sought reelection to complete some unfinished business in Mississippi including assisting small businesses, helping veterans, strengthening the military, and completing flood-control projects in Jackson, Miss., and the Delta.

“Some tax provisions that encourage job creation are about to expire. We need to renew those and make sure we take the regulatory burden off small businesses owners. They’re the ones who created the jobs in America,” he told the Mississippi Free Press on Tuesday.

Pinkins told the Mississippi Free Press that he ran for U.S. Senate, in part, because rich farm owners in the Delta had brought in white South African immigrants to do work and paid them more during training than they paid the Black farmers who had been working on the farms for years.

Pinkins’ campaign also focused on supporting women’s reproductive rights, including the right to abortion.

Wicker has fought to restrict abortion rights multiple times since he started his time in the U.S. Senate in 2007. He also voted against federal protections for same-sex couples. Pinkins ran in support of codifying protections offered under Roe v. Wade before the U.S. Supreme Court overturned it.

“Thank you for your unwavering support, your votes, and for giving me the privilege of representing your hopes and your aspirations,” Pinkins wrote in a tweet on Wednesday.

With 98% of the vote counted as of Wednesday at 10:20 a.m., Wicker secured 63% of the vote, with 668,802 Mississippians choosing him for reelection; Pinkins got 37% of the vote with 393,330 Mississippians selecting him on their ballots.

Mississippi’s four incumbents in the House of Representatives also all won reelection. Republican U.S. House Rep. Trent Kelly won 69.9% of the vote while Democrat Dianne Dodson Black won 30.1% in Mississippi’s 1st Congressional District.

Democratic U.S. House Rep. Bennie Thompson secured 61.7% of the vote over Republican candidate Ron Eller’s 38.3% in Mississippi’s 2nd Congressional District. Thompson is the only Democrat in Mississippi’s congressional delegation. He told the press at his watch party in Bolton, Miss., that some of his top priorities are helping Mississippi’s health care system, building hospitals in rural areas, upgrading the highway system and sponsoring a farm bill to support the agricultural industry.

“We have to have a farm bill that benefits everyone, not just the rich, but everyone. And so I hope to go back and work on a farm bill that’s balanced on who supports it but also who the beneficiaries are,” he said on Tuesday night.

Republican U.S. Rep. Michael Guest ran unopposed in Mississippi’s 3rd Congressional District and won. 

“I’m honored to be re-elected to serve as your congressman and to represent our conservative values in our nation’s capital,” Guest tweeted on Tuesday evening.

In Mississippi’s 4th Congressional District, Republican U.S. House Rep. Mike Ezell won 74.6% of the vote and just 25.4% of people voted for Democrat Craig Raybon, who said in October that he was withdrawing from the race.

“I’ll continue to be an open book. Come to Washington, we’ll take care of you. Anything I can do for my office as far as your congressman, I’ll be glad to help,” Ezell told WLOX on Tuesday night.

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