I.

These cases involve payments made by health insurers1 for the prescription drug Seroquel, an antipsychotic medication2 manufactured and marketed in the United States by AstraZeneca Pharmaceuticals LP (“AstraZeneca”). Seroquel has received Food and Drug Administration (“FDA”) approval for the treatment of schizophrenia and bipolar disorder.3 The drug, however, has been used to treat *1356various other diseases and disorders, even though the FDA has not approved it for such uses. The practice of prescribing a drug for a use not approved by the FDA, commonly referred to as “off-label” use, is both legal and commonplace in the medical community.4

The insurers claim that physicians prescribed Seroquel for many of these off-label uses because AstraZeneca fraudulently induced them to do so. Specifically, the insurers say that AstraZeneca, through an illegal off-label marketing campaign, falsely represented that Seroquel was safer and more effective in treating many off-label conditions than less expensive drugs also used to treat those conditions.5 Physicians, in turn, relying on AstraZeneca’s false representations, prescribed Seroquel instead of the cheaper — and sometimes safer or more effective — substitutes for the insurers’ insureds (“enrollees”). As a result, because the insurers’ insurance policies covered payment for Seroquel — either in full or in part, depending on whether the policies obligated enrollees to pay a prescription drug copayment (“co-pay”)6 — the insurers *1357claim that AstraZeneca’s fraud caused them “to unnecessarily pay for [the more expensive] Seroquel off-label prescriptions.” Absent the fraud, they say they would have paid less for their enrollees’ prescription drugs. Consequently, the insurers seek to recover the difference between the amount that was paid for the off-label Seroquel prescriptions and the amount that would have been paid for the less expensive substitutes.7

A.

Each of the cases before us is a class action brought against AstraZeneca8 on behalf of all third-party payers for health care services.9 One of the cases, in addition to being brought on behalf of a group of insurers, includes a claim by an individual enrollee, Cheryl Martin, a resident of Tennessee. Martin, like the insurers, paid for an off-label prescription of Seroquel instead of a less expensive substitute.10 She seeks to represent a class of similarly situated enrollees.

The allegations of these cases have been merged within a consolidated complaint consisting of seven counts.11 Counts I and II seek treble damages under the civil provision of the federal Racketeer Influenced and Corrupt Organizations Act (“RICO”), 18 U.S.C. § 1964(c).12 *1358Count I is based on 18 U.S.C. § 1962(c).13 It alleges that AstraZeneca has marketed Seroquel through an “enterprise” and that its false representations to physicians concerning Seroquel’s superior safety and efficacy constitutes “a pattern of racketeering activity” — i.e., violations of the mail and wire fraud statutes.14 Count II is based on 18 U.S.C. § 1962(d).15 It alleges that AstraZeneca conspired to commit the substantive § 1962(c) offense. Finally, counts III-VII, respectively, seek damages under the consumer protection statutes and the common law of forty-six States.16

B.

AstraZeneca moved the district court to dismiss the plaintiffs’ claims under Federal Rule of Civil Procedure 12(b)(6), and the court granted its motion. See Ironworkers Local Union No. 68 v. AstraZeneca Pharms. LP, 585 F.Supp.2d 1339, 1342, 1347 (M.D.Fla. 2008). The court ruled that the complaint did not adequately plead that AstraZeneca’s false representations proximately caused the plaintiffs’ purported economic losses.17 Id at 1345-47.

The court first noted the proximate causation a RICO plaintiff must establish to make out a case under 1964(c): a plaintiff has to show “some direct relation between *1359the injury asserted and the injurious conduct alleged.” Holmes v. Sec. Investor Prot. Corp., 503 U.S. 258, 268 112 S.Ct. 1311, 1318 117 L.Ed.2d 532 (1992) (emphasis added). The court concluded that the complaint’s allegations failed to establish a direct relation between AstraZeneca’s false representations and the plaintiffs’ losses. Instead, the allegations showed that the plaintiffs’ losses could have been “caused by other, independent, factors.” 585 F.Supp.2d at 1344. Key among such factors — and a potential independent intervening cause — was that Seroquel was prescribed by physicians in the exercise of their independent professional judgment, and such judgment could be informed by sources other than AstraZeneca’s “representations ... [regarding the] drug’s relative safety and efficacy.” Id. Ascertaining whether and, if so, to what extent AstraZeneca’s representations caused a physician to prescribe Seroquel off-label in a given situation would amount to a “highly complex damages assessment,” id. at 1345, that “would require an inquiry into the specifics of [the] doctor-patient relationship,” id. at 1344. This complex assessment, the district court concluded, weighed against a finding of direct injury to the plaintiffs as a result of AstraZeneca’s conduct, and the court therefore dismissed the plaintiffs’ RICO claims. Id. at 1345.

The district court subsequently dismissed the state law18 consumer protection and common law claims on the same proximate causation ground that required the dismissal of the RICO claims.19 The court then entered a final judgment for AstraZeneca in conformance with its order dismissing the plaintiffs’ complaint, and the plaintiffs lodged this appeal.

II.

“We review de novo the district court’s grant of a motion to dismiss under 12(b)(6) for failure to state a claim, accepting the allegations in the complaint as true and construing them in the light most favorable to the plaintiff.” Am. Dental Ass’n v. Cigna Corp., 605 F.3d 1283, 1288 (11th Cir. 2010). In assessing the sufficiency of the complaint’s allegations, we are bound to apply the pleading standard articulated in Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007), and Ashcroft v. Iqbal, — U.S. —, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009). That is, the complaint “must ... contain sufficient factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’ ” Am. Dental Ass’n, 605 F.3d at 1289 (quoting Twombly, 550 U.S. at 570, 127 S.Ct. at 1974) (emphasis added).

*1360Applying these standards, we affirm the district court’s judgment; however, we do so on grounds different from those employed by the district court. See Powers v. United States, 996 F.2d 1121, 1123-24 (11th Cir. 1993) (“We may affirm the district court’s judgment on any ground that appears in the record, whether or not that ground was relied upon or even considered by the court below.” (citations omitted)). As subpart A presents, economic injury is a necessary element of all of the plaintiffs’ claims, and, in the context of prescription drug purchases, the fact that the payer merelypaid for more expensive drugs does not suffice. Instead, the purchased drugs must have been either unsafe or ineffective for their prescribed use — i.e., the prescription needs to have been medically unnecessary or inappropriate according to sound medical practice.20

In subpart B, we affirm the district court’s dismissal of the insurers’ claims in all seven counts of the complaint. The insurers, under the terms of their insurance policies, consciously exposed themselves to pay for all prescriptions of Seroquel, including those that were medically unnecessary or inappropriate — even if such prescriptions were birthed by fraud. In light of such broad exposure, conventionally a rational insurer would have charged its enrollees higher premiums than it would have if its policies offered more limited prescription drug coverage. These higher premiums, in turn, would compensate the insurer for its increased number of prescription payments, including payments for prescriptions that were medically unnecessary or inappropriate. Moreover, to the extent the insurer’s payments for medically unnecessary or inappropriate prescriptions exceeded the premiums charged, only actuarial errors would be to blame. Here, the insurers plead no facts to suggest that they somehow established premiums in a manner distinct from this conventional understanding; consequently, the district court had to dismiss their claims because they failed to allege plausibly that AstraZeneca’s false representations caused them to suffer economic injury.

In subpart C, we affirm the district court’s dismissal of the claims brought by the individual enrollee, Cheryl Martin, because the complaint fails to allege any facts concerning her economic injury from payment for medically unnecessary or inappropriate drugs that would satisfy the Twombly and Iqbal plausibility standard.

A.

Section 1 of this subpart highlights that economic injury is an essential element that must be alleged under each of the plaintiffs’ causes of action. From there, section 2 establishes that, to assert a plausible economic injury arising from the purchase of prescription drugs, the plaintiffs must have alleged that the purchased drugs either were medically unnecessary or inappropriate for their prescribed use.

*13611.

A plaintiff asserting a claim under § 1964(c) of RICO must allege economic injury arising from the defendant’s actions. Sedima, S.P.R.L. v. Imrex Co., Inc., 473 U.S. 479, 496, 105 S.Ct. 3275, 3285, 87 L.Ed.2d 346 (1985) (declaring that a § 1964(c) plaintiff “only has standing if, and can only recover to the extent that, he has been injured in his business or property by the conduct constituting the [RICO] violation”). A “defendant who violates section 1962 is not liable for treble damages to everyone he might have injured by other conduct, nor is the defendant liable to those who have not been injured.” Id. at 496-97, 105 S.Ct. at 3285 (emphasis added) (citations omitted). Although the Supreme Court has demanded that “RICO is to be read broadly,” id. at 497, 105 S.Ct. at 3285, the injury to business or property limitation on RICO standing has a “restrictive significance,” Reiter v. Sonotone Corp., 442 U.S. 330, 339, 99 S.Ct. 2326, 2331, 60 L.Ed.2d 931 (1979). It “helps to assure that RICO is not expanded to provide a federal cause of action and treble damages to every tort plaintiff.” Steele v. Hosp. Corp. of Am., 36 F.3d 69, 70 (9th Cir. 1994) (citations omitted) (internal quotation marks omitted); see also Maio v. Aetna, Inc., 221 F.3d 472, 483 (3d Cir. 2000) (quoting Steele, 36 F.3d at 70). Otherwise, “[t]o allow recovery by persons who have not been injured or to allow recovery for an injury greater than that caused by the offending conduct would run counter to the plain language of [18 U.S.C. § 1964(c)].” Sikes v. Teleline, Inc., 281 F.3d 1350, 1365 (11th Cir. 2002) (citations omitted), abrogated on other grounds by Bridge v. Phoenix Bond & Indem. Co., 553 U.S. 639, 128 S.Ct. 2131, 170 L.Ed.2d 1012 (2008).

Injury also is a necessary element of each of the plaintiffs’ claims based on state law.21 For instance, the consumer protection laws of New Jersey, Pennsylvania and Tennessee require that a plaintiff allege an “ascertainable loss” of money as a result of the defendant’s fraudulent or deceitful conduct. See N.J. Stat. Ann. § 56:8-19 (West 2010) (“Any person who suffers any ascertainable loss of moneys ... as a result of the use or employment by another person of any method, act, or practice declared unlawful under this act ... may bring an action or assert a counterclaim therefor in any court of competent jurisdiction.” (emphasis added)); 73 Pa.Stat. Ann. § 201-9.2(a) (West 2010) (creating a similar private right of action in any consumer of goods who suffers an “ascertainable loss of money” by way of statutorily proscribed fraudulent or deceitful acts); Tenn.Code Ann. § 47-18-109(a)(1) (West 2010) (“Any person who suffers an ascertainable loss of money ... as a result of the use or employment by another person of an unfair or deceptive act or practice declared to be unlawful by this part, may bring an action individually to recover actual damages.” (emphasis added)). Moreover in New Jersey, Pennsylvania, and Tennessee, without allegations of injury, a claim is not remediable when based either on common law fraud, see, e.g., Banco Popular N. Am. v. Gandi, 184 N.J. 161, 876 A.2d 253, 260 (2005) (stating that to establish common law fraud in New Jersey, a plaintiff must plead and prove “resulting damages” from the defendant’s material misrepresentation); First Nat’l Bank v. Brooks Farms, 821 S.W.2d 925, 927 (Tenn. 1991) (declaring that injury to the plaintiff caused by reasonable reliance on an intentional misrepresentation is an element of Tennessee

*1362common law fraud); Scaife Co. v. Rockwell-Standard Corp., 446 Pa. 280, 285 A.2d 451, 454 (1971) (citations omitted) (declaring that “damage to the recipient” of a fraudulent misrepresentation is a necessary element of Pennsylvania common law fraud), or negligent misrepresentation, see e.g., Bortz v. Noon, 556 Pa. 489, 729 A.2d 555, 561 (1999) (stating that in Pennsylvania, “[n]egligent misrepresentation requires ... injury to a party acting in justifiable reliance on the [negligently made] misrepresentation.” (emphasis added) (citations omitted)); H. Rosenblum, Inc. v. Adler, 93 N.J. 324, 461 A.2d 138, 142-43 (1983) (stating that in New Jersey, “[a]n incorrect statement, negligently made and justifiably relied upon, may be the basis for recovery of damages for economic loss or injury sustained as a consequence of that reliance”), superseded on other grounds by statute, N.J. Stat. Ann. § 2A:53A-25 (West 2010), as recognized in Finderne Mgmt. Co. v. Barrett, 355 N.J.Super. 197, 809 A.2d 857, 862 (2002); Jasper Aviation, Inc. v. McCollum Aviation, Inc., 497 S.W.2d 240, 242-43 (Tenn. 1972) (stating that plaintiffs may recover for pecuniary loss caused to them by their justifiable reliance on a negligently made misrepresentation).

2.

Although there is a dearth of Eleventh Circuit precedent on the issue, for tort-based causes of action, the scope of potential economic injury arising from a patient’s — or her health insurer’s — purchases of prescription drugs is limited. As the district court noted, when a doctor prescribes a drug, he presumably does so only if, in the exercise of his independent medical judgment, he believes the drug will benefit his patient. See Ironworkers Local Union No. 68, 585 F.Supp.2d at 1344 (“Presumably ... physicians use their independent medical judgment to decide whether Seroquel is the best treatment for a given patient.”). This presumption applies regardless of whether the prescription is for an FDA-approved or off-label use.

Several considerations shape the physician’s medical judgment, including both individual patient concerns and drug-specific information regarding the propriety of a drug’s use for treatment of a patient’s given condition — that is, a drug’s relevant safety and efficacy under the circumstances. See, e.g., Reyes v. Wyeth Labs., 498 F.2d 1264, 1276 (5th Cir. 1974)22 (“The [prescription] choice [the physician] makes is an informed one, an individualized medical judgment bottomed on a knowledge of both patient and palliative.”); UFCW Local 1776 v. Eli Lilly & Co., 620 F.3d 121, 135 (2d Cir. 2010) (discussing how a patient’s diagnosis, any past and current medications the patient has taken, the physician’s experience with prescribing the drug, and the physician’s knowledge regarding the drug’s side effects all function as considerations taken into account in addition to the alleged misrepresentations distributed by a drug manufacturer); see also McCombs v. Synthes, 277 Ga. 252, 587 S.E.2d 594, 595 (2003) (“[T]he decision to employ prescription medication ... involves professional assessment of medical risks in light of the physician’s knowledge of a patient’s particular need and susceptibilities.” (citations omitted) (internal quotation marks omitted)). The physician learns about a drug through multiple sources, only one of which might be the drug manufacturer’s promotions and literature. For instance, physicians typically *1363obtain additional information about a drug’s putative uses from journals, meetings, and conventions.

In light of physicians’ exercise of professional judgment, a patient suffers no economic injury merely by being prescribed and paying for a more expensive drug; instead, the prescription additionally must have been unnecessary or inappropriate according to sound medical practice — i.e., the drug was either ineffective or unsafe for the prescribed use. This is true even when the physician’s decision to prescribe the more expensive drug in lieu of a cheaper alternative is the product of fraud. See, e.g., Heindel v. Pfizer, Inc., 381 F.Supp.2d 364, 380 (D.N.J. 2004) (concluding that there is no economic injury for the purchase of a prescription drug when the drug proves at all beneficial to the patient prescribed it (quoting In re Rezulin Prods. Liab. Litig., 210 F.R.D. 61, 68-69 (S.D.N.Y. 2002))). To allow recovery based purely on the fact that the prescription was comparatively more expensive than an alternative drug — but otherwise safe and effective — would mean that physicians owe their patients a professional duty to consider a drug’s price when making a prescription decision.

No such duty exists. While it might be true, as the complaint states, that “[t]he medical community generally encourages physicians to prescribe the most effective and cost-efficient treatment for their patients,” Second Am. Consol. Compl. ¶ 70, “[pjhysicians generally do not take the price of a drug into account when deciding among treatment options, and often do not even know the price of the drugs they prescribe. This is particularly true in the treatment of mental disorders, which is an extremely individualized process.” UFCW Local 1776, 620 F.3d at 126-27.

Rather, to assert an economic injury, the plaintiff must allege that her purchase payments were the product of a physician’s medically unnecessary or inappropriate prescriptions. The issue of whether prescriptions are medically unnecessary or inappropriate- — like most health care delivery questions — depends on the standards of practice in the medical profession. See, e.g., Barry R. Furrow et al., Health Law: Cases, Materials, and Problems 336 n.2 (6th ed. 2008) [hereinafter Furrow et al.] (“The medical profession sets standards of practice and the courts have historically enforced these standards in tort suits.”). Therefore, the prescription allegedly must be one that, in the practice of profession-accepted sound medicine, the physician should not have prescribed because the drug was unsafe or ineffective for its prescribed use. See, e.g., Rivera v. Wyeth-Ayerst Labs., 283 F.3d 315, 319-21 (5th Cir. 2002) (finding that plaintiffs lacked Article III standing because they did not assert a concrete injury arising from their purchase of prescription painkillers when the drugs were not alleged to have been ineffective in treating the plaintiffs’ conditions or to have caused them physical injury).

Thus, when a physician’s decision to prescribe a drug for a particular use purportedly was caused by false representations concerning the drug’s safety and efficacy in that use, a plaintiff must allege that she not only paid for the drug, but also that its prescription was medically unnecessary or inappropriate. To make this showing, the payer-plaintiff must allege a counterfactual: that her physician— had he known all the true information about the medication — would not have prescribed the drug under the standards of sound medical practice because the drug actually was unsafe or ineffective in treating the plaintiffs condition. See, e.g., In re Schering-Plough Corp. Intron/Temodar Consumer Class Action, No. 2:06-cv-5774, *13642009 WL 2043604, at *16-20 (D.N.J. 2009) (concluding, in a case with similar facts, that insurers failed to plead RICO injury to their business or property where they failed to allege that their enrollees “ ‘received inadequate [or] inferior [drugs] or even worse, suffered personal injuries as a result of Defendants’ alleged misrepresentations.’ ” (quoting Maio, 221 F.3d at 488)).

B.

In light of the principles presented in subpart A, we turn now to the insurers’ allegations. In short, we find that the insurers have not alleged plausible economic injury arising from their payments for medically unnecessary or inappropriate off-label Seroquel prescriptions caused by AstraZeneca’s false representations to physicians. Insurers, to sustain profitability, charge their enrollees an up-front fee, i.e., a “premium,” in exchange for insurance coverage. Typically, insurers adjust premiums to compensate for known risks assumed under that coverage. Here, the insurers assumed the risk of paying for all prescriptions of drugs covered by their policies, including medically unnecessary or inappropriate prescriptions — even those caused by fraudulent marketing. The insurers, however, have not pled any facts to suggest plausibly that they did not charge their enrollees premiums or, in turn, adjust those premiums to compensate for this known risk.23 Furthermore, to the extent the insurers’ payments for medically unnecessary or inappropriate off-label Seroquel prescriptions exceeded the premiums they collected, AstraZeneca should not be held liable for the insurers’ actuarial errors.

1.

In general, health insurers enter into a contractual bargain with enrollees in which, in exchange for their service — assuming the risk of payment for enrollees’ future health care costs — they receive a “premium,” an up-front fee that represents the price of the insurance policy.24 See Furrow et al., supra, at 643 (defining insurance generally as the contractual transfer of risk from the insured party to a financing entity, the insurer, in consideration for premium). The premium charged enrollees is essential to insurers’ goal of profitable outcomes from their insurance bargains. Insurers are making a conscious gamble with profitability: will *1365the premiums they receive be sufficient to cover the risks they have assumed?

The premiums charged may or may not be sufficient to cover the claims the insurers pay; when the claims exceed the insurers’ projections, they bear the loss. When, however, the premiums received exceed the value of the claims paid by the insurers, the enrollees bear the loss because the insurers keep the remaining premium proceeds. Thus, in sum, the insurance contract represents a conscious bargain in which both sides hope to, at least, come out even — but know they might not.

Because of how paramount premiums are to their profitability, insurers engage in a technical actuarial analysis to price them. Through this ratemaking process, insurers aim to “predict[] future losses and future expenses and allocat[e] those costs among the various classes of insureds.”25 Staff of H. Comm, on Educ. & Labor, 100th Cong., Insuring the Uninsured: Options and Analysis (Comm. Print 1988), as reprinted in Furrow et al., supra, at 645 (internal quotation marks omitted) (describing the ratemaking process). Insurers predict losses on the basis of predicted claims costs. This prediction involves an assessment of (1) the likely number of times a covered event— e.g., a prescription of a covered drug — will occur and (2) the average cost of each covered event. Id., as reprinted in Furrow et al., supra, at 645. If there is any uncertainty surrounding projected claims, insurers will raise the premium to reflect that uncertainty. The final premium charged consists of this adjusted estimate plus an administrative expenses projection that includes estimates for all those expenses that the insurance company charges that are not for claims, such as overhead.26 Id., as reprinted in Furrow et al., supra, at 645.

Because the value of estimated claims drives the premium rate, the premium charged for a policy largely depends on the scope of coverage under that policy. The broader the coverage offered — i.e., the more health care services indemnified by the insurer — the higher the premiums charged for that policy. In other words, covering more health care services creates a likelihood of more claims and, correspondingly, a greater projected claims value. The insurer will fund these higher costs through escalated premiums.

*13662.

In the present matter, the insurers’ policies broadly covered prescriptions of Seroquel because it was listed on the insurers’ drug formularies. Drug formularies, in brief, are insurers’ lists of medications approved for coverage. See UFCW Local 1776, 620 F.3d at 126 (discussing generally the common use and operation of drug formularies in the prescription drug insurance industry). Formularies are managed by Pharmacy Benefit Managers (“PBMs”), which act as agents for the insurers.27 The PBMs list a drug on the insurers’ formularies— which frequently consist of at least three tiers of approved drugs28 — only after they have approvingly assessed the drug’s clinical safety, efficacy, and cost effectiveness for its FDA-approved uses. Seroquel went through this PBM approval process and was listed on the insurers’ formularies based upon its FDA-approved uses in the treatment of schizophrenia and bipolar disorder.29

Although placed on the formularies based only upon its FDA-approved uses, Seroquel’s placement on those formularies contractually obligated the insurers to pay the drug’s price anytime it was prescribed. Therefore, the insurers had to pay regardless of the facts surrounding that prescription; they had to pay if the drug was prescribed for an FDA-approved use or an off-label use — even if the prescription was medically unnecessary or inappropriate.

The insurers, however, could have excluded coverage for medically unnecessary or inappropriate prescriptions of Seroquel and other formulary-listed drugs.30 The complaint itself suggests one technique available to them: preauthorization review. See Second Am. Consol. Compl. ¶ 276 (declaring that, had the insurers known of AstraZeneca’s scheme, they “could have ... required pre-authorization” prior to their paying for off-label Seroquel prescriptions). In brief, preauthorization review entails “case-by-case evaluations conducted by insurers ... to determine the necessity and appropriateness ... of medical care” prior to delivery of that care to an enrollee. See, e.g., Furrow et al., supra, at 673 (discussing the operation of these costs controls generally). Therefore, preauthorization review of drug prescriptions provides insurers with a process to monitor the prescription, dispensing, and

*1367use patterns of medications to promote appropriate uses of covered drugs.31 See Kevin J. Dunne & Ciara R. Ryan, How Management of Medical Costs is Revolutionizing the Drug Industry, 62 Def. Couns. J. 177, 178-79 (1995) (explaining the operation of insurers’ drug utilization review systems, including preauthorization review). When a preauthorization review of a proposed prescription finds that prescription to be medically inappropriate or unnecessary, the insurer will deny payment for the drug before the enrollee ever receives it.32 See Furrow et ah, supra, at 673, 674 (stating that preauthorization review “denies payment for experimental and medically unnecessary [prescriptions] because such [prescriptions are] not covered under the plan contract.”). In turn, because preauthorization review avoids insurers’ payment for medically unnecessary or inappropriate drugs, insurers that utilize it decrease the value of their projected claims and, correspondingly, may reduce the premiums they charge enrollees.

Here, however, the insurers made the conscious business decision not to require preauthorization review in their policies. The complaint, by suggesting that the insurers could have required preauthorization review for off-label Seroquel, see Second Am. Consol. Compl. ¶ 276, avows that the insurers have the capacity to utilize the procedure.33 Yet, they chose not to. Instead, they voluntarily assumed the risk of paying for all prescriptions of *1368Seroquel, including prescriptions for off-label uses that were medically unnecessary or inappropriate.

Their enrollees, however, we must infer from our common understanding of insurance practices — as well as common sense — did not receive this extensive prescription drug coverage for free. The insurers have pled no facts in the complaint that suggest the insurers established premiums in a way inconsistent with the insurance industry’s conventional ratemaking procedures. We therefore must infer that the insurers do charge premiums established in that conventional manner. As a consequence, because the insurers consciously chose to assume the risk of paying for all medically unnecessary or inappropriate prescriptions of formulary-listed drugs — like Seroquel — we must further infer that they adjusted their premiums upward to reflect the projected value of claims for these prescriptions.34 Such estimates, when calculated properly, take into account all known risks that might cause the insurers to pay for medically unnecessary or inappropriate prescriptions.

One such risk is fraud within the health care industry. Fraud is a well-known contributor to increased costs for health care services. See Furrow et al., supra, at 570 (“Fraud and abuse probably account for more than a trivial share of health care costs — aggressive enforcement of fraud and abuse laws appears to have played a role in decreasing Medicare costs in the late 1990s.”); see also Nat’l Health Care Anti-Fraud Assoc., The Problem of Health Care Fraud, http://www.nhcaa.org/eweb/ DynamicPage.aspx?webcode=anti_fraucL resource_centr fewpscode=TheProblemOf HCFraud (estimating “conservatively” that at least 3% of all health care spending— $68 billion — is lost to health care fraud annually). Thus, the risk that fraud- — -including fraudulent marketing by drug manufactures — might result in insurers paying for medically unnecessary or inappropriate prescriptions is just another cost to be factored into premiums.

As discussed generally in part II.B.l, supra, the insurers gambled that their estimates would prove sufficient to cover their payments for all medically unnecessary or inappropriate off-label Seroquel prescriptions. If their estimates exceeded the actual payments for these drugs, then the insurers paid nothing out of pocket to purchase Seroquel; instead, they earned a profit on their bargain. See, e.g., Int'l *1369Bhd. of Teamsters Local 731 Health & Welfare Trust Fund v. Philip Morris Inc., 196 F.3d 818, 823 (7th Cir. 1999) (declaring that similar insurers, “[h]aving collected extra money from [insured] smokers” based on premiums assessed by “actuaries whose life work is making accurate estimates of the costs of smoking ... and enabling the insurer to collect these in advance from insureds,” cannot also recover that extra cost from tobacco manufacturers). If the insurers achieved this outcome, then their enrollees lost — having paid for more prescription drug coverage than they needed. If, however, the insurers’ estimates fell short of actual payments, their own business mistakes caused their loss. AstraZeneca cannot be held to reinsure the insurers’ sophisticated actuarial decisions.35

Either way, the insurers have not alleged facts suggesting that they plausibly suffered economic injury caused by AstraZeneca’s false representations. Therefore, because they have not met their Twombly and Iqbal pleading burden, we affirm the district court and dismiss the entirety of the insurers’ claims.

C.

We now address the allegations raised by the individual enrollee, Cheryl Martin, of whom we know very little from the complaint. In fact, the complaint discusses Martin only once, stating that, since 2003, she “has paid for a portion of her Seroquel prescription which was prescribed for her by her physician for an off-label use.” Second Am. Consol. Compl. ¶ 26. Thus, unlike the insurers, Martin has paid out of her own pocket to purchase off-label Seroquel prescriptions. As a result, she potentially has viable claims against AstraZeneca based on her prescription of Seroquel in lieu of cheaper substitutes.36

Yet, as presented in part II.A.2, supra, allegations of out-of-pocket overpayment in the purchase of prescription drugs do not, alone, give rise to an actionable injury, notwithstanding the presence of underlying fraud. Rather, Martin, to meet her pleading burden under Twombly and Iqbal, must allege that she plausibly purchased medically unnecessary or inappropriate Seroquel prescriptions. Martin’s bareboned allegations in the complaint, however, do not meet this burden. Nowhere in the complaint does she state the medical condition for which Seroquel was prescribed off-label, let alone whether Seroquel proved unsafe or ineffective in treating her condition.37 Because Martin *1370has failed to assert these basic and essential facts, she has not pled a plausible actionable loss on account of AstraZeneca’s fraud. As a consequence, we affirm the district court and dismiss her claims.

III.

To summarize, we affirm the judgment of the district court dismissing the entirety of the complaint for failing to state a claim upon which relief can be granted. We reach this conclusion, however, on different grounds: the insurers and Martin fail to allege sufficient facts suggesting they suffered a plausible injury from AstraZeneca’s false representations regarding Seroquel’s off-label benefits.

AFFIRMED.

concurring in the result:

I agree with the majority’s conclusion that this action must be dismissed, but I concur specially to express my view that there is a much simpler reason why the appellees should prevail. As the Second Circuit explained in UFCW Local 1776 v. Eli Lilly & Co., 620 F.3d 121 (2d Cir. 2010), the independent decisions of the physicians and other intermediaries involved in Seroquel’s allegedly increased usage and pricing eviscerates the chain of causation necessary to demonstrate a RICO violation. See id. at 134-36. I believe that these breaks in the chain of causation, which were conceded by the appellants in their complaint and at oral argument, dictate the result of this appeal. I therefore do not join the broader analysis of the majority opinion, and concur in the outcome only.