Connecticut insurance regulators have fined OptumRX Inc. $10,500 for failing to meet state requirements when denying coverage for medications and delays in responding to urgent care requests. The Connecticut Insurance Department cited the pharmacy benefit manager for 14 violations during 2023, according to a consent order signed Oct. 10. The company neither admitted nor denied […]
Connecticut insurance regulators have fined OptumRX Inc. $10,500 for failing to meet state requirements when denying coverage for medications and delays in responding to urgent care requests.
The Connecticut Insurance Department cited the pharmacy benefit manager for 14 violations during 2023, according to a consent order signed Oct. 10. The company neither admitted nor denied the allegations.
OptumRX, a California-based subsidiary of health insurance giant UnitedHealth Group, failed to respond to three urgent care requests within the state-mandated 48 to 72 hours, according to the CID’s market conduct examination.
The company also did not give patients the required 45 days to provide additional information before denying coverage in five cases.
In six other instances, OptumRX failed to provide proper web links for patients to access the clinical criteria used to deny their medication requests, regulators found.
The violations occurred during a 10-month period from February through December 2023, according to Insurance Commissioner Andrew N. Mais.
OptumRX has agreed to review its utilization review practices and procedures and bring them into compliance with Connecticut law. The company must submit a full report of its corrective actions within 90 days.
The violations relate to Section 38a-591 of Connecticut General Statutes, which governs how utilization review entities must handle coverage determinations and appeals.
OptumRX is licensed in Connecticut as a utilization review entity and manages prescription drug benefits for health insurers and employers. The company is one of the nation's largest pharmacy benefit managers, also known as PBMs.
PBMs have
faced growing criticism from state and federal officials over business practices that critics say can delay patient care and drive up costs.
