Shanon and William, of Poynette, filed their negligence lawsuit against Walgreens and its parent company Boots Alliance and Optum Rx, the pharmacy benefits manager, in federal court in Milwaukee on January 21, 2025, a year to the day that their son Cole died.
Cole’s prescription had been covered under his insurance, Optum Rx, which is owned by UnitedHealth Group. Previously the medication had cost no more than $66.86 (without deductible) and $35 (with deductible). However, on Jan. 10, 2024, when Cole arrived at his usual Walgreens pharmacy, the suit alleges that he was told his medication was no longer covered and he needed to pay out-of-pocket a total cost of $539.19.
Lawyers said that Cole was not given enough time to request an exception to the new guideline that “suddenly made his normal medication prohibitively expensive.”
Optum Rx said that Schmidtknecht filled a generic Albuterol prescription, an inhaler used to stop asthma attacks, on January10, 2024, with a $5 copay, adding that the same drug was previously filled in October 2023 by him.
Optum Rx-Walgreens Negligence Lawsuit
Schmidtknecht’s lawsuit states that Optum Rx had a duty to not artificially inflate prescription drug prices for medications such as Advair Diskus for insured patients, including, making them so unaffordable that patients could not obtain the medications their physicians prescribed.” His parents said that Cole struggled to breathe over the next five days. He could only use an old ‘rescue’ (emergency) inhaler to limit his symptoms, because he did not have the preventative inhaler designed for daily use.
Further, the Schmidtknechts accuse that pharmacy benefits management company OptumRX of violating Wisconsin law by raising the cost of the medication without a valid medical reason and failing to provide 30 days’ advance notice of drug price increases. “The conduct of both OptumRx and Walgreens was deplorable,” one of the family’s attorneys said in a statement. “The evidence in this case will show that both OptumRx and Walgreens put profits first, and are directly responsible for Cole’s death.”
“Walgreens Defendants failed to exercise reasonable care in that they knew, or should have known, of the unreasonable risk of harm to asthmatic patients, including Cole Schmidtknecht, that would result from their failing to provide him with Advair Diskus or a medically equivalent alternative medication at an affordable price at the point of service.”
Albuterol
The Independent reported that OptumRx last April reviewed Cole’s claims showed that on the day he visited the pharmacy, he did buy a different asthma medication, generic Albuterol, for a $5 co-pay on January 10, 2024 — a medication that it says he also obtained in October 2023. His case was handled “consistent with industry practice and the patient’s insurance plan design,” the company said.
The prescription service said that it “also has available clinically appropriate options and formulary information” for when medication is not covered by a provider. The $5 generic prescription Cole filled was for his rescue inhaler, not the Advair Diskus inhaler that he needed daily.
And this from the Washington Post:
“For many years, the standard treatment for asthma was an inhaler with a medication called albuterol. Only if that wasn’t enough would additional medicines be added. If symptoms became especially bad, patients would receive oral steroids. There are several problems with this approach. To start, it hasn’t been working well. Data from the Centers for Disease Control and Prevention in 2019 shows that more than 60 percent of asthmatic adults had uncontrolled asthma, frequently sending them to the emergency department or forcing them to miss work. Severe asthma can also be fatal; an average of 10 Americans die every day because of it, and in nearly every case, the death is preventable with the right treatment.”
Albuterol also does not address the actual problem. Asthma is a chronic inflammatory disease of the lungs.
Thanks to emerging research, guidelines for asthma treatment have been shifting away from albuterol-only and toward steroid-containing inhalers. In 2022, the Global Initiative for Asthma (GINA) — a collaboration between the World Health Organization and the National Institutes of Health — issued landmark recommendations to change the paradigm of asthma care. These new guidelines no longer endorse treating asthma with albuterol, a short-acting medication. Instead, they recommend that all adults, adolescents and most children with asthma receive inhalers containing steroids and a long-acting medicine to relax lung muscles. Patients with moderate-to-severe asthma should use the inhaler every day.
More about Advair Diskus
According to the Mayo Clinic, Albuterol is commonly called a “rescue” inhaler, used to stop attacks while they’re happening. Albuterol is used to treat or prevent bronchospasm in patients with asthma, bronchitis, emphysema, and other lung diseases. It is also used to prevent bronchospasm caused by exercise. Advair Diskus inhalation is a steroid and bronchodilator combination medicine that is used to prevent asthma attacks. It is also used to prevent flare-ups or worsening of chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis and/or emphysema.
This is how dangerous it was for Cole without the inhaler he was prescribed and needed:
- Do not stop using this medicine or any asthma medicine without telling your doctor. To do so may increase the chance for breathing problems. If you miss a dose of this medicine, take it as soon as possible.
- Get medical help right away if your breathing problems get worse, if you need your rescue inhaler more often than usual or it does not work as well to relieve your symptoms, or if your peak flow meter results decrease.
According to a health expert, a generic medication may not be the solution. The unfortunate reality is that sometimes, you pick one based on what the patient’s insurance carrier is,” said one doctor. “If you’re not sure which combination medication is covered by your health insurance, talk to your pharmacist. Cole had no one to talk to.
More About UnitedHealth and OptumRx
In December 2023, UnitedHealth and its pharmacy benefit manager OptumRx were sued by an independent pharmacy for purportedly bullying pharmacies into agreeing to “unconscionable” performance-based fees, threatening their financial health.
The lawsuit claims OptumRx sets performance metrics and calculates DIR fees, then forces pharmacies to pay the fees to remain in its network for Medicare Part D, Medicare’s prescription drug benefit. The fees are unfair, given they rely in part on metrics that pharmacies don’t control like patient outcomes or which drugs a doctor chooses to prescribe, the lawsuit says.
“Many of the performance criteria established by OptumRx make little or no sense for pharmacies,” the lawsuit argues, calling the fees “nonsensical” and “arbitrary.”
If independent pharmacies don’t accept the fees, they would be forced out of network with OptumRx and lose a valuable revenue stream. OptumRx contracts with plans covering almost one-quarter of Medicare beneficiaries in PBM-affiliated plans, according to a Drug Channels report cited in the suit.
And in December 2024, Attorney General Coleman added OptumRx to an existing lawsuit for reckless opioid administration against Express Scripts. OptumRx is a pharmacy benefit manager (PBM) contracting with the manufacturers of opioids, the pharmacies that dispense them and the third-party payors who pay for them. According to the Attorney General’s lawsuit, Optum Rx played a central role in the reckless promotion, dispensing, and oversupply of opioids.
Optum Rx controls a pharmacy network consisting of approximately 67,000 retail pharmacy locations nationwide, it services prescription claims for more than 66 million people across the U.S. T according to the lawsuit.
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