AdvancePCS v. Bauer

617 S.E.2d 637, 274 Ga. App. 381, 2005 Fulton County D. Rep. 2216, 36 Employee Benefits Cas. (BNA) 1315, 2005 Ga. App. LEXIS 769
CourtCourt of Appeals of Georgia
DecidedJuly 13, 2005
DocketA05A0455
StatusPublished
Cited by3 cases

This text of 617 S.E.2d 637 (AdvancePCS v. Bauer) is published on Counsel Stack Legal Research, covering Court of Appeals of Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
AdvancePCS v. Bauer, 617 S.E.2d 637, 274 Ga. App. 381, 2005 Fulton County D. Rep. 2216, 36 Employee Benefits Cas. (BNA) 1315, 2005 Ga. App. LEXIS 769 (Ga. Ct. App. 2005).

Opinions

Phipps, Judge.

Deborah R. Bauer and Diane G. Wright, on behalf of themselves and those similarly situated, filed a class action complaint against AdvancePCS, PCS Health Systems, Inc., PCS Mail Services of Fort Worth, Inc. and PCS Mail Services of Birmingham, Inc. (collectively, PCS) for their alleged wrongful classification of the generic drug tamoxifen as a brand name drug. PCS initially removed the case to federal court based on its assertion that the action was completely preempted by the provisions of the Employee Retirement Income Security Act of 1974 (ERISA), 29 USC § 1001 et seq., as amended. Bauer and Wright filed a motion to remand the action to state court, and that motion was granted. PCS then filed a motion to dismiss the state court action for lack of subject matter jurisdiction, contending that Bauer and Wright’s claims related to ERISA employee benefit plans and were therefore preempted under ERISA § 514 (a), 29 USC § 1144 (a). The trial court denied the motion. On appeal, PCS claims that the trial court erred in concluding that Bauer and Wright’s state cause of action was not preempted by ERISA. We agree with the trial court’s conclusion and affirm the denial of PCS’s motion to dismiss.

Bauer and Wright are breast cancer survivors who were prescribed the drug tamoxifen to prevent the cancer from recurring. AdvancePCS and PCS Health Systems, Inc. are pharmacy benefit management companies who provide services such as processing [382]*382prescription drug claims to various health insurance payors, including self-insured employers, insurance companies, health maintenance organizations and similar organizations. PCS Mail Services of Fort Worth, Inc. and PCS Mail Services of Birmingham, Inc. are mail order pharmacies who, with the help of AdvancePCS and PCS Health Systems, sell prescription drugs directly to consumers whose prescription drug benefits are processed by AdvancePCS and/or PCS Health Systems.

Bauer and Wright had major medical coverage provided by their respective employers. AdvancePCS or PCS Health Systems was the pharmaceutical benefit manager for Bauer and Wright’s medical coverage plans.1 Those plans required a co-payment for prescription drugs, and the co-payment was higher for brand name drugs than for generic drugs. PCS classified tamoxifen as a brand name drug. As a result, Bauer and Wright were required to make the higher co-payment.

Bauer and Wright claimed that PCS benefitted financially from the improper classification of tamoxifen as a brand name drug and sought to require them to disgorge those economic benefits. The only theory of recovery they asserted was unjust enrichment. PCS claimed that Bauer and Wright’s cause of action was preempted by ERISA and argue on appeal that the trial court erred by concluding otherwise.

ERISAregulates plans providing employees with fringe benefits. It “is a comprehensive statute designed to promote the interests of employees and their beneficiaries in employee benefit plans.”2 ERISA imposes certain requirements on pension and welfare plans, but does not require that employers provide any particular benefits.3

ERISA § 514 (a), 29 USC § 1144 (a), provides that, with certain exceptions not relevant here, ERISA “shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan” covered by ERISA. “The term ‘State law’ includes all laws, decisions, rules, regulations, or other State action having the effect of law, of any State.”4

Section 514 (a) was intended to ensure that plans and plan sponsors would be subject to a uniform body of benefits law; the goal was to minimize the administrative and financial burden of complying with conflicting directives among States [383]*383or between States and the Federal Government. Otherwise, the inefficiencies created could work to the detriment of plan beneficiaries.5

With those purposes in mind, we consider whether Bauer and Wright’s unjust enrichment cause of action “relates to” their employee benefit plans such that it would be expressly preempted by ERISA§ 514 (a).6 Alaw “relates to” an employee benefit plan if it has a connection with or reference to such a plan, but § 514 (a) is not limited to state laws specifically designed to affect employee benefit plans.7 And although § 514 (a) has been broadly construed, the United States Supreme Court has recognized that “[s]ome state actions may affect employee benefit plans in too tenuous, remote, or peripheral a manner to warrant a finding that the law ‘relates to’ the plan.”8

We do not find a sufficient connection between the state law claims asserted here and the ERISAbenefit plans at issue to conclude that the claims “relate to” those plans. Bauer and Wright are not seeking, directly or indirectly, to recover benefits due them under their respective plans — they do not claim that they are entitled to any benefits from their plans that they have not received.9 Instead, they claim that PCS misclassified the drug tamoxifen and that the erroneous classification was not based on the terms of their plans.10

Contrary to the dissent’s argument, Bauer and Wright’s unjust enrichment claims are not disguised claims for prescription drug benefits. Their claims for tamoxifen were covered by their respective plans. The plans paid for their portion of tamoxifen, based on PCS’s classification of the drug as brand name.11 It was PCS, not the plans or plan sponsors, who required Bauer and Wright to pay the higher [384]*384co-payment. And PCS’s classification of tamoxifen as brand name was not based on the terms of the plans, but on information PCS received from a third party.

Further, contrary to PCS’s claims, the trial court will not be required to interpret the provisions of the respective plans to address Bauer and Wright’s claims. The only issue requiring reference to the plans is the price difference between the co-payment for a brand name drug and the co-payment for a generic drug. The fact that the remedy sought may affect the plan because any damages awarded to Bauer and Wright, if they ultimately prevail, will be measured based on the difference between the two co-payment amounts, as set forth in the plans, is not enough for preemption.12

In addition, Bauer and Wright have not asserted claims against their plans, their employers or any other ERISA entity. In Morstein v. Nat. Ins. Svcs.,13 the United States Court of Appeals for the Eleventh Circuit held that “when a state law claim brought against a nonERISA entity does not affect relations among principal ERISA entities as such, then it is not preempted by ERISA.”14 ERISA entities include the employer, the plan, the plan fiduciaries and the beneficiaries under the plan.15 The parties agree that PCS merely processes prescription drug claims and is not a fiduciary of the plans. Thus, the principal ERISA entities in this case are Bauer and Wright, their employers and their benefit plans. We agree with the trial court’s conclusion that this lawsuit does not affect the relationship between those principal ERISA entities.

PCS relies heavily on the United States Supreme Court’s decision in

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Related

AdvancePCS v. Bauer
642 S.E.2d 342 (Court of Appeals of Georgia, 2007)
Advance PCS v. Bauer
632 S.E.2d 95 (Supreme Court of Georgia, 2006)

Cite This Page — Counsel Stack

Bluebook (online)
617 S.E.2d 637, 274 Ga. App. 381, 2005 Fulton County D. Rep. 2216, 36 Employee Benefits Cas. (BNA) 1315, 2005 Ga. App. LEXIS 769, Counsel Stack Legal Research, https://law.counselstack.com/opinion/advancepcs-v-bauer-gactapp-2005.