JONES v. CVS HEALTH CORPORATION

CourtDistrict Court, E.D. Pennsylvania
DecidedOctober 31, 2024
Docket2:24-cv-01703
StatusUnknown

This text of JONES v. CVS HEALTH CORPORATION (JONES v. CVS HEALTH CORPORATION) is published on Counsel Stack Legal Research, covering District Court, E.D. Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
JONES v. CVS HEALTH CORPORATION, (E.D. Pa. 2024).

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA

DENISE ELAYNE JONES and : MARILYN A. MANZI, individually and : on behalf of all other similarly situated, : : Civil Action Plaintiffs, : : No. 24-cv-1703 v. : : CVS HEALTH CORPORATION, f/k/a CVS : CAREMARK CORPORATION, : SILVERSCRIPT INSURANCE COMPANY, : LLC, CAREMARK L.L.C., f/k/a CAREMARK INC., CVS PHARMACY, INC., and CVS CAREMARK PART D SERVICES, LLC.

Defendants.

MEMORANDUM J. Younge October 31, 2024 I. INTRODUCTION Plaintiffs Denise Elayne Jones and Marilyn A. Manzi (“Plaintiffs”) bring this action individually and on behalf of all other similar situated against Defendants CVS Health Corporation, f/k/a CVS Caremark Corporation (“CVS Health”), SilverScript Insurance Company, LLC (“SilverScript”), Caremark L.L.C., f/k/a Caremark Inc., CVS Caremark Part D Services, LLC (together, “CVS Caremark”), and CVS Pharmacy, Inc. (“CVS Pharmacy”) (collectively herein “Defendants”). The Complaint alleges that Defendants colluded and conspired with pharmaceutical manufacturers to deny Medicaid Part D beneficiaries access to less expensive generic alternatives to name-brand drugs, violating the Racketeer Influenced and Corrupt Organizations Act (“RICO”), 18 U.S.C. §§ 1962, et. seq., and various state laws. (Compl. ¶¶ 15, 93). Currently before this Court is Defendants’ Motion to Dismiss pursuant to the Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6). (ECF No. 19.)1 The Court finds this Motion appropriate for resolution without oral argument. Fed. R. Civ. P. 78; L.R. 7.1(f). For the reasons set forth in this Memorandum, Defendants’ Motion is GRANTED in PART and DENIED in PART. II. FACTUAL BACKGROUND

The facts of this case are similar to those discussed by this Court in United States ex rel. Ellsworth Assoc., LLP v. CVS Health Corp., 660 F. Supp. 3d 381 (E.D. Pa. 2023). As in that case, the Court will begin its discussion by outlining how Medicare Part D operates to provide context for the scheme alleged by Plaintiffs. A. Medicare Part D Medicare is the federally funded health insurance program for people who are sixty-five or older and younger people with certain disabilities or end-stage renal disease. (Defendant’s Brief in Support of Motion to Dismiss, ECF No. 19-1 (“Def.’s Brief”), p. 2; Compl. ¶ 81). It is comprised of four parts: Parts A, B, C, and D. (Def.’s Brief, p. 2). Part D, Medicare’s optional

prescription-drug coverage, is designed as a public-private partnership. (Def.’s Brief, p. 3). As such, Medicare enters into contracts with private companies, known as Part D sponsors (“PDPs” or “Sponsors”), to sponsor Part D plans in which Medicare-eligible individuals can then enroll. (Def.’s Brief, p. 3; Compl. ¶ 2). SilverScript, which is owned by CVS Health, is one such Sponsor who contracts with the Centers for Medicare & Medcaid Services (“CMS”) (part of the Department of Health & Human Services). (Compl. ¶ 2; Def.’s Brief, p. 3). An essential feature of each Part D plan is its formulary, which is a list of drugs covered by said plan. (Compl. ¶ 83). Pharmacy Benefit Managers (“PBMs”), like CVS Caremark, decide

1 When applicable, the Court adopts the pagination supplied by the CM/ECF docketing system, which does not always match the document’s internal pagination. which drugs a plan will pay for and then negotiate the prices of those drugs with pharmaceutical companies. (Compl. ¶¶ 27, 35). Congress, in its construction of the Act, did not dictate which drugs a plan must include on its formulary. (Def.’s Brief, p. 3) As such, the Act prohibits CMS from requiring a particular formulary, but instead implements a process where would-be plan Sponsors submit their formularies for approval. (Def.’s Brief, p. 3, 6).

As part of a PBM’s negotiations of prices to create their formularies, drug manufacturers can offer discounts of their drugs, which PBMs can take a cut of through rebates. (Compl. ¶ 36). In theory, these rebate arrangements would incentivize PBMs to negotiate lower drug prices for Sponsors to pass along to their members. (Compl. ¶ 36). However, as Plaintiffs allege, this process can also be used to create competitive restrictions that increase costs, as drug manufacturers may squelch out competition from cheaper drugs by conditioning the rebates on giving their product preferred status. (Compl. ¶ 139). Plan beneficiaries seeking a drug that is not included in their formulary must either purchase the drug outside of their coverage or request a formulary exception to extend coverage to said drug. (Compl. ¶ 83).

B. The Alleged Scheme Plaintiffs allege that Defendants, along with five of the largest manufacturers of name- brand drug products (the Manufacturer Co-Conspirators)2, implemented a fraudulent scheme to prevent Plaintiffs and other Medicare Part D beneficiaries covered by SilverScript plans from accessing cheaper generic equivalent versions of the prescription drugs Invega, Asacol HD, Renvela packets, Renvela tablets, Harvoni, Epclusa, Ventolin HFA, Canasa Recta Suppository,

2 The Manufacturer Co-Conspirators are Janssen Pharmaceuticals, Inc., the manufacturer of Invega; Allergan plc (now owned by AbbVie Inc.), the manufacturer of Asacol HD and Canasa Rectal Suppository; Sanofi-Aventis U.S. LLC, the manufacturer of Renvela packets and Renvela tablets; Gilead Sciences, Inc., the manufacturer of Harvoni and Epclusa; and GlaxoSmithKline, the manufacturer of Ventolin HFA and Advair Diskus. (Compl. ¶ 1, n.1) and Advair Diskus (together, the “Affected Drugs”). (Compl. ¶ 1). In this purported scheme (hereinafter the “No Generic Scheme” or “NG Scheme”), starting around 2015, Defendants allegedly received lucrative rebates from the Manufacturer Co-Conspirators in exchange for obstructing SilverScript beneficiaries’ access to generic versions of the Affected Drugs. (Compl. ¶¶ 3, 102). In other words, Plaintiffs’ claim that SilverScript’s decision to place the Affected

Drugs on their formulary was not the product of arms-length negotiations, but rather the terms of an improper collusion between Defendants and the Manufacturer Co-Conspirators. (Compl. ¶ 3). In furtherance of the NG Scheme, Defendants allegedly manipulated CVS Pharmacies to block their customers from filling their prescriptions with generic drugs, ultimately ensuring that SilverScript plan beneficiaries could only fill their prescriptions with name-brand versions of the Affected Drugs included in the formulary. (Compl. ¶¶ 104-105). According to a confidential witness employed as a Staff Pharmacist in a CVS Pharmacy (“CW1”), CVS Pharmacy’s drug dispensation system, which routes all prescription requests electronically to CVS Caremark for determination and approval, would restrict pharmacist from dispensing the generic version of

certain Affected Drugs. (Compl. ¶ 104). Further, CVS Pharmacies would often have inadequate stock of certain generic drugs, while simultaneously maintaining an unusual overstock of the name-brand drug. (Compl. ¶ 105). As a result, even if the system allowed a pharmacist to dispense a generic drug, they might not be able to fill the prescription with the generic due to inventory shortages. (Compl. ¶ 105). According to another confidential witness employed as Pharmacy Benefits Manager at CVS Health between 2020 and 2023 (“CW2”), who made similar claims as CW1, these practices “felt like CVS was forcing people to take the more expensive medications,” making SilverScript beneficiaries “pretty much hit a dead end.” (Compl. ¶ 119).

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JONES v. CVS HEALTH CORPORATION, Counsel Stack Legal Research, https://law.counselstack.com/opinion/jones-v-cvs-health-corporation-paed-2024.