In re Express Scripts/Anthem Erisa Litig.

285 F. Supp. 3d 655
CourtDistrict Court, S.D. Illinois
DecidedJanuary 5, 2018
Docket16 Civ. 3399 (ER)
StatusPublished
Cited by15 cases

This text of 285 F. Supp. 3d 655 (In re Express Scripts/Anthem Erisa Litig.) is published on Counsel Stack Legal Research, covering District Court, S.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
In re Express Scripts/Anthem Erisa Litig., 285 F. Supp. 3d 655 (S.D. Ill. 2018).

Opinion

Ramos, D.J.:

This litigation arises out of the relationship between Anthem, Inc. ("Anthem"), one of the nation's largest health benefits companies, and Express Scripts, Inc. ("ESI"), a pharmacy benefits manager ("PBM"), and the impact of their transactions on Plaintiffs, a proposed class of certain Anthem health plans and individual subscribers to Anthem health plans who receive prescription drug benefits through ESI. Plaintiffs assert seventeen causes of action against Anthem and ESI ("Defendants"), including causes of action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., the Racketeering Influenced and Corrupt Organizations Act ("RICO"), 18 U.S.C. § 1961 et seq., and the Patient Protection and Affordable Care Act ("ACA") anti-discrimination provision, 42 U.S.C. § 18116.

On April 24, 2017, both Anthem and ESI moved to dismiss the Plaintiffs' Second Amended Complaint ("SAC") (Doc. 78). Docs. 93, 96. For the reasons stated below, both motions are GRANTED.

I. BACKGROUND1

A. Anthem and ESI's 2009 PBM Agreement

Anthem is health benefits company that provides health care insurance and insurance administration programs. SAC ¶ 3. Anthem offers health care plans sponsored through an employer (Employee Welfare Benefit Plans regulated under ERISA) or offered directly from Anthem through, for example, the ACA insurance exchanges. Id. Anthem also provides "Administrative Services Only" ("ASO") plans to self-funded employers. Id. In an ASO plan, the health plan reimburses the health care costs of the plan beneficiaries, but pays Anthem a premium to administer the plan (and to negotiate on its behalf for lower rates with health care providers). Id. ¶ 9. ASO plans account for sixty percent of Anthem's business. Id. ¶ 10.

To keep costs of prescription medications manageable, insurers like Anthem *663frequently use in-house or third-party PBMs to administer prescription medication programs for health plans. Id. ¶¶ 108, 121 ("A critical key to success for health insurers is to provide effective and affordable pharmacy/drug related services and administration for its members ....") (quoting Complaint (Doc. 1), at ¶ 11, Anthem v. Express Scripts, Inc., No. 16 Civ. 2048 (S.D.N.Y. 2016) ). PBMs generally contract with pharmacies, negotiate discounts and rebates with drug manufacturers, review drug utilization, manage drug formularies, and process and pay prescription drug claims. Id.

ESI is the largest PBM operating in the United States. Id. ¶ 109. Over 97% of the pharmacies in the country are in an ESI network. Id. ESI processes nearly 1.4 billion prescriptions each year. Id. ESI provides traditional PBM services and also operates mail-order delivery services for prescription drugs. Id. ¶ 108.

On December 1, 2009, Anthem and ESI entered into a ten year agreement (the "PBM Agreement"). Id. ¶ 103. Under the PBM Agreement, ESI either processes claims of Anthem participants who fill prescriptions at retail pharmacies or fills the prescriptions of Anthem participants directly through its mail-order pharmacies. Id. ¶ 112. ESI also provides administrative services relating to prescription drugs for Anthem, Anthem's health plans, and Anthem participants. Id. ¶ 122.

On the same day, Anthem and ESI entered into an agreement by which Anthem sold three PBM companies, NextRx, LLC, NextRx, Inc., and NextRx Services (collectively, the "NextRx companies") to ESI (the "NextRx Agreement"). Id. ¶ 125.2 The execution of the PBM Agreement was a condition precedent to the signing of the NextRx Agreement. Id. ¶ 126. According to ESI, the purchase price for the NextRx entities was directly tied to the price Anthem would pay for prescription drugs over the course of the PBM Agreement.

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Bluebook (online)
285 F. Supp. 3d 655, Counsel Stack Legal Research, https://law.counselstack.com/opinion/in-re-express-scriptsanthem-erisa-litig-ilsd-2018.