In re Epipen Erisa Litig.
In re Epipen Erisa Litig.
Opinion of the Court
This matter is before the Court on Defendants' Motions to Dismiss. For the following reasons, the Motions are granted in part and denied in part.
BACKGROUND
The individual Plaintiffs in these consolidated putative class actions are participants in health insurance plans that are subject to the requirements of the Employee Retirement Income Security Act ("ERISA"),
*1017Class Action Compl. (Docket No. 196) ¶¶ 11-29.)
Defendants CVS Health Corporation, CaremarkPCS Health L.L.C, Caremark L.L.C., Caremark Rx L.L.C. (collectively, "CVS Caremark"), Express Scripts Holding Company, Express Scripts, Inc., Medco Health Solutions, Inc. (collectively, "Express Scripts"), UnitedHealthGroup, Inc., UnitedHealthcare Services, Inc., Optum, Inc., Optum Rx Holdings, LLC, OptumRx, Inc. (collectively, "Optum"), and Prime Therapeutics, LLC are pharmacy benefit managers, or PBMs. PBMs are "middlemen" in the prescription-drug-benefit market. They develop and maintain lists of drugs, known as formularies, from which participants in a health-insurance plan must choose for their pharmaceutical needs. They also negotiate with drug manufacturers and distributors for volume discounts and rebates in exchange for inclusion and preferential placement of the drug on formularies, and exclusion of competitor's drugs from formularies. According to Plaintiffs, Defendants control more than 80% of the prescription-drug-benefit market "and possess the market power of more than 200 million" Americans. (Compl. ¶ 2.)
Plaintiffs allege that Defendants' negotiations with Mylan caused Mylan to raise the price of EpiPens, while Defendants pocketed millions of dollars in rebates and other payments. Because the price Mylan charges for EpiPens directly affects the amount a plan's beneficiaries pay for the EpiPens, Mylan's price increases raised Plaintiffs' out-of-pocket costs dramatically. (Id. ¶ 7.) Plaintiffs assert that Defendants breached their fiduciary duties under ERISA § 404(a),
Defendants seek dismissal of the Complaint under Rule 12(b)(1), arguing that Plaintiffs cannot establish that their injuries are traceable to Defendants' conduct, nor are their injuries redressable by the injunctive relief they seek, and thus Plaintiffs lack standing to pursue their claims. In the alternative, Defendants contend that Plaintiffs have failed to state any claims on which relief can be granted under Rule 12(b)(6) because the PBMs are not ERISA fiduciaries.
DISCUSSION
To survive a motion to dismiss under Rule 12(b)(6), a complaint need only "contain sufficient factual matter, accepted as true, to 'state a claim to relief that is plausible on its face.' " Ashcroft v. Iqbal,
A. Standing
1. Injury
Plaintiffs claim to have suffered injury in the form of higher copayment and deductible costs for purchasing the EpiPens they require. Defendants contend that this injury is not fairly traceable to the conduct complained of. According to Defendants, the higher price for EpiPens is a function only of Mylan's business decisions. But Plaintiffs have plausibly alleged that Defendants' demands for rebates and other payments caused Mylan to raise the price of EpiPens. At this preliminary stage of the litigation, that is sufficient.
2. Redressability
Defendants do not take issue with Plaintiffs' standing as to monetary or other equitable relief, contending only that the requested injunctive relief will not redress their injuries. But if the Court were to enter an injunction in Plaintiffs' favor, it is plausible that Mylan would lower the price of EpiPens as a result. Again, at this preliminary stage, Plaintiffs have sufficiently alleged that their injuries would be redressed by an injunction.
Defendants' Motion under 12(b)(1) is denied.
B. Fiduciary Duties
ERISA imposes on all plan fiduciaries the duty of prudence and loyalty.
A party may become an ERISA fiduciary by being designated as such in the plan documents or if a named fiduciary expressly delegates fiduciary authority to the party pursuant to the plan's terms. Abraha v. Colonial Parking, Inc.,
A party may also become a fiduciary "by exercising de facto control over an area of plan management or administration." Id."[A] party not specifically named as a fiduciary of a plan owes a fiduciary duty only 'to the extent' that party (i) exercises any discretionary authority or control over management of the plan or its assets; (ii) offers 'investment advice for a fee' to plan members; or (iii) has 'discretionary authority' over plan 'administration.' " McCaffree Fin. Corp. v. Principal Life Ins. Co.,
*10191. Discretion
Defendants argue that they are not fiduciaries because the amount of the rebates or other fees that they pay the plans are set by contracts that were negotiated at arm's length. See, e.g., Hecker v. Deere & Co.,
Defendants cite to excerpts from their contracts with health insurers or other health benefit plans in arguing that these agreements do not give them discretion to set the fees they charge to the plans. But Plaintiffs dispute this contention, arguing that Defendants could and did change how they characterized drug-manufacturer payments-as rebates, administrative fees, or other types of payments-to allow Defendants to keep more of the money and pay less to the plans. Thus, according to Plaintiffs, Defendants controlled the amount of their compensation.
On a motion to dismiss, the consideration of evidence is not appropriate. Defendants contend that the contracts between them and the plans are necessarily subsumed by the pleadings, but at this preliminary stage, the Court will not construe the complicated and multi-faceted agreements at issue here as a matter of law. See BJC Health Sys. v. Columbia Cas. Co.,
Plaintiffs have plausibly alleged that Defendants control the amount they receive in rebates or other fees from Mylan and likewise exercise discretion over how much of that money is paid to the plans. This conduct is different from that at issue in the cases Defendants cite, such as the Carpenters case above. In that case, the plan asserted that the PBM was a fiduciary with regard to the payments specified in the contracts between the plan and the PBM. Here, on the other hand, Plaintiffs assert that the fiduciary relationship stems not from the required contractual payments, but from the PBMs' actions that line its own pockets at the expense of plan participants.
Defendants' reliance on In re UnitedHealth Group PBM Litigation, Civ. No. 16-3352,
2. Breach of fiduciary duties
Plaintiffs have plausibly alleged that Defendants breached their fiduciary duties under section 404(b). Plaintiffs assert that Defendants negotiated such large "rebates" and other payments from Mylan that it caused Plaintiffs' out-of-pocket expenses for EpiPens to increase exponentially. At this stage, that is sufficient to plead a breach.
3. Self-dealing
Plaintiffs also claim that Defendants have violated ERISA's prohibition on fiduciary self-dealing. Plaintiffs claim specifically that Defendants' conduct constitutes (1) dealing with plan assets in Defendants' own interest,
Defendants first contend that Plaintiffs have failed to plausibly allege that Defendants acted to benefit themselves as the expense of the plan or plan participants. To support this argument, they point to Plaintiffs' allegation regarding EpiPen's net price, which has remained relatively flat. (Defs.' Supp. Mem. (Docket No. 214) at 49 (citing Compl. ¶ 118).) But Plaintiffs allege that Defendants' rebate and fee deals with Mylan raised the list price of EpiPens, not the net price, and that Plaintiffs' out-of-pocket expenses, for coinsurance or pre-deductible payments, were tied to the list price, not the net price. (Compl. ¶¶ 125, 132.) Thus, Plaintiffs have sufficiently alleged that Defendants' conduct was at the expense of plan participants and the plans themselves.
Defendants also contend that Plaintiffs' self-dealing claims fail because there are no plan assets involved.
But rather than argue explicitly that Defendants' market power is a plan asset, Plaintiffs instead claim that the administrative services agreements between the plans and insurers, or the contracts between plans and PBMs, constitute plan assets. Alternatively, they contend that the drug formularies are plan assets, or that the excess amounts that the plans or Plaintiffs must pay for EpiPens as a result of Defendants' negotiated rebates and fees are plan assets.
Although ERISA does not define what constitutes plan assets, "[t]he Secretary of Labor has repeatedly defined 'plan assets' consistently with 'ordinary notions of property rights.' " Kalda v. Sioux Valley Physician Partners, Inc.,
The agreements between Defendants and Mylan are not plan assets-the plans have no property rights in agreements to which they are not parties. Nor are the administrative services agreements between plans and insurers plan assets for purposes of any fiduciary duty on the part of Defendants, because Defendants are not parties to these agreements. The only possible plan assets involved here are the contracts between Defendants and the plans themselves.
But the conduct Plaintiffs allege here is extra-contractual-it is conduct that is contrary to either the letter or spirit of the contracts between Defendants and the plans. For example, Plaintiffs assert that, although Defendants are contractually required to remit the "rebates" they receive from Mylan to the plans, Defendants characterize payments from Mylan as "fees" or other types of payments, thereby avoiding the contractual requirements. This conduct, while plausibly a breach of § 1104, as discussed above, does not involve plan assets or transactions for purposes of ERISA's self-dealing prohibitions. Plaintiffs' claims under § 1106 therefore fail.
CONCLUSION
Plaintiffs have plausibly alleged that they suffered an injury that is redressable by the relief they seek. They have also plausibly pleaded their fiduciary-duty claim under ERISA § 404 but have not done so under § 406. Accordingly, IT IS HEREBY ORDERED that :
1. CVS Caremark's Motion to Dismiss (Docket No. 209) is GRANTED in part and DENIED in part ;
2. Express Script's Motion to Dismiss (Docket No. 210) is GRANTED in part and DENIED in part ;
3. Optum's Motion to Dismiss (Docket No. 211) is GRANTED in part and DENIED in part ; and
4. Prime Therapeutics's Motion to Dismiss (Docket No. 212) is GRANTED in part and DENIED in part .
The Court will hereafter refer to the Consolidated Class Action Complaint as simply the Complaint.
The involvement of plan assets is relevant both for Plaintiffs' self-dealing claims and Plaintiffs' alternative argument that Defendants are plan fiduciaries because Defendants "exercise[d] any authority or control respecting management or disposition of [a plan's] assets" under § 1002(21)(A)(i), which imposes fiduciary responsibilities without regard to a party's discretionary authority or control. Having determined that Plaintiffs plausibly alleged Defendants' fiduciary status with respect to plan administration, the Court need not determine whether Defendants exercised control of the management or disposition of plan assets.
Reference
- Full Case Name
- IN RE: EPIPEN ERISA LITIGATION
- Cited By
- 2 cases
- Status
- Published