Urias v. PCS Health Systems, Inc.

118 P.3d 29, 211 Ariz. 81, 458 Ariz. Adv. Rep. 3, 2005 Ariz. App. LEXIS 99
CourtCourt of Appeals of Arizona
DecidedAugust 18, 2005
Docket1 CA-CV 03-0717
StatusPublished
Cited by46 cases

This text of 118 P.3d 29 (Urias v. PCS Health Systems, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals of Arizona primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Urias v. PCS Health Systems, Inc., 118 P.3d 29, 211 Ariz. 81, 458 Ariz. Adv. Rep. 3, 2005 Ariz. App. LEXIS 99 (Ark. Ct. App. 2005).

Opinion

OPINION

GEMMILL, Judge.

¶ 1 Premier Healthcare, Inc., an insurer, owed money to PCS Health Systems, Inc. for *82 prescription drug reimbursement payments. PCS had gathered volume discount rebates from drug manufacturers and was obligated to pay eighty-five percent of the rebates to Premier. After Premier was placed into receivership, PCS asserted the right under Arizona Revised Statutes (“A.R.S.”) section 20-638(A) (2002) to retain the rebate funds owed to Premier as an offset against Premier’s indebtedness to PCS. To decide whether this offset is authorized, we must determine if the obligations were “mutual debts” within the meaning of A.R.S. § 20-638(A). Because we decide that the obligations were “mutual debts” and may be set off in accordance with § 20-638(A), we affirm the summary judgment granted in favor of PCS against Premier. 1

FACTS AND PROCEDURAL BACKGROUND

¶ 2 Premier operated as an Arizona health care services organization offering health insurance plans to employer groups and Medicare-eligible individuals (collectively its “Members”). These plans included certain prescription drugs. To fulfill its prescription drug services obligation, Premier entered into a Managed Pharmaceutical Benefit Agreement (the “Agreement”) with PCS. Under the Agreement, PCS provided services that included pharmacy management, claims processing, drug utilization review, and for-mulary services. The Agreement established a fee schedule for the various services provided by PCS.

¶ 3 The pharmacy management services provided by PCS included access for Premier’s Members to pharmacies under contract to PCS that had agreed to perform pharmacy services in accordance with the reimbursement schedule and other “processing parameters” established by Premier. PCS agreed to process claims submitted by its network pharmacies and by Premier Members directly. The Agreement provided that the dispensing pharmacy must collect any applicable copayments or coinsurance or deductibles from the Member and that “PCS will pay the dispensing pharmacy the balance, if any, of the agreed upon reimbursement amount.”

¶4 Section 3.2 of the Agreement established the method for reimbursement by Premier for pharmaceutical benefits provided to Premier’s members:

Drug Reimbursement. When, as part of the Services, PCS reimburses Network Pharmacies or Members in connection with Benefits, Premier shall pay to PCS all amounts disbursed or to be disbursed by PCS. PCS shall establish a payment cycle for reimbursement of Network Pharmacies for Benefits provided to Members____Fol-lowing each cycle, PCS shall send to Premier via facsimile an- advice specifying the charges applicable to such cycle. Premier shall wire that amount within 48 hours to the bank account designated by PCS and established for that purpose.

PCS generally did not pay claims to the pharmacies until PCS had received payment from its customers such as Premier.

¶5 In addition to the pharmacy management services, the Agreement required PCS to provide a “formulary service.” This service included development of a drug formu-lary and the performance of a retrospective review of drug utilization and prescribing patterns in order to obtain rebates from drug manufacturers. Section D of the formulary services component of the Agreement provided:

Rebate Contracts. PCS will attempt to contract with certain manufacturers for volume rebate programs. Premier acknowledges that whether and to what extent manufacturers are willing to provide rebates will depend upon the Plan design adopted by Premier, and other aspects of Premier’s drug benefit program, as well as PCS receiving sufficient information regarding each claim submitted to manufacturers for rebates.

*83 ¶ 6 In return for the agreement by PCS to attempt to negotiate these rebates, Premier agreed not to participate “in any other for-mulary or similar volume discount program during the term of the Agreement.” Premier also agreed not to enter into any direct contracts with pharmaceutical manufacturers for volume discounts during the term of the Agreement or for one year from termination of the Agreement.

¶ 7 The term “rebate” was defined as “all rebates, reimbursements or other discounts received under a Manufacturer’s discount program with respect to pharmaceutical products dispensed to a Member under the Plan,” but was not to include “any fees or other compensation” paid by the manufacturer to PCS for its own account for administrative or other fees. PCS was required to report annually to Premier regarding the administrative fees paid to PCS by each manufacturer with respect to the pharmaceutical products dispensed to Premier’s members.

¶8 The rebate services portion of the Agreement also provided:

On behalf of Premier, PCS will receive the Rebates paid by manufacturers to Premier. PCS will make payments of such Rebates once each calendar quarter as follows: within 60 days of the beginning of each quarter, PCS will pay to Premier all Rebates received by PCS during the prior quarter.
Along with each payment of Premier Rebates, PCS will provide a report which includes the Manufacturer’s name, the number of prescriptions and/or amount of dollar purchases for each Manufacturer, and the total amount of Rebates paid by each Manufacturer.

Premier did not control the manner in which PCS negotiated and secured the rebates. Premier was given the right, however, to audit the volume discount contracts from the manufacturers from time to time at its own expense. Premier “acknowledge[d] and agree[d] that PCS will not be responsible in any manner for any failure of any Manufacturer to pay any Rebate.”

¶ 9 The fee to be paid to PCS for its formulary services, including “the negotiation, collection and distribution of rebates,’ was fifteen percent of the rebates collected by PCS. In agreeing to this amount, Premier acknowledged that it “received and considered an estimate of the potential range of Rebates under its Plan.” Premier also agreed that PCS could retain its fifteen percent fee from any rebates “collected by PCS on behalf of Premier in connection with this Agreement.”

¶ 10 To summarize, the PCS network pharmacies bought pharmaceuticals from manufacturers, provided those pharmaceuticals to Premier Members, and submitted claims at intervals to PCS, which, in turn, invoiced Premier. Premier paid PCS “within 48 hours” and PCS then paid its network pharmacies. PCS gathered information regarding the dollar amount or number of prescriptions attributable to the purchase of pharmaceuticals for Premier Members from various manufacturers and used this information to negotiate rebates or volume discounts from those manufacturers participating in a rebate program. PCS collected these rebate funds and remitted them to Premier at quarterly intervals, minus PCS’s fifteen percent fee. PCS maintained separate accounting for the collection and remittance of rebate funds.

¶ 11 This arrangement continued with apparent satisfaction on all fronts until Premier was placed in receivership for insolvency on November 16,1999.

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Cite This Page — Counsel Stack

Bluebook (online)
118 P.3d 29, 211 Ariz. 81, 458 Ariz. Adv. Rep. 3, 2005 Ariz. App. LEXIS 99, Counsel Stack Legal Research, https://law.counselstack.com/opinion/urias-v-pcs-health-systems-inc-arizctapp-2005.