New England Carpenters Health Benefits Fund v. First Databank, Inc.

244 F.R.D. 79, 68 Fed. R. Serv. 3d 1467, 42 Employee Benefits Cas. (BNA) 1433, 2007 U.S. Dist. LEXIS 63159, 2007 WL 2416516
District Court, D. Massachusetts·Decided August 27, 2007·No. Civil Action No. 05-11148-PBS·Published·Cited by 12 cases

Opinion

MEMORANDUM AND ORDER

SARIS, District Judge.

I. INTRODUCTION

In this proposed national class action, plaintiffs allege that First DataBank, Inc. and McKesson Corporation engaged in a racketeering enterprise to fraudulently state the “average wholesale price” for numerous prescription pharmaceuticals beginning in late 2001, in violation of 18 U.S.C. § 1964 and California state law.1

After hearing, pursuant to Fed.R.Civ.P. 23(a) & (b)(3), I certify the following two [81] classes for a period covering August 1, 2001 to March 15, 2005:

Class 1, Consumer Purchasers: All individual persons who paid, or incurred a debt enforceable at the time of judgment in this case to pay, a percentage co-payment for the Marked Up Drugs during the Class Period based on AWP, pursuant to a plan, which in turn reimbursed the cost of brand-name pharmaceutical drugs based on AWP. The Marked Up Drugs include all of the drugs identified in Exhibit A to the Second Amended Complaint and consist of certain brand-name drugs only; and Class 2, Third-Party Payors: All third-party payors (1) the pharmaceutical payments of which were based on AWP during the Class Period; (2) that made reimbursements for drugs based on an AWP that was marked up from 20 to 25% during the term of its contract with its PBM or with another entity involved in drug reimbursement; and (3) that used First DataBank or Medispan for determining the AWP of the marked up drugs. The Marked Up Drugs are all drugs identified in Exhibit A and consist of brand-name drugs only.
Excluded from the Class are (a) each defendant and any entity in which any defendant has a controlling interest, and their legal representatives, officers, directors, assignees and successors; (b) any co-conspirators; and (c) any governmental entities that purchased such drugs during the class period.

At this juncture, Class 1 is certified for liability and for damages, but Class 2 is only certified for liability and for equitable relief. I defer deciding whether to certify the TPP class for purposes of damages until plaintiffs propose a feasible aggregate damage methodology for TPPs.

The “Marked Up Drugs” identified in the class definition are brand-name, self-administered drugs sold through retail pharmacies, including mail order.

II. BACKGROUND FACTS

The Second Amended Complaint, Proffer of Evidence, and expert reports of Robert D. Willig,2 defendant’s expert, and of Raymond Hartman,3 plaintiffs’ expert, provide evidence to support the following facts, many of which are disputed. I have also considered certain facts established during the related multidistrict litigation. See In re Pharm. Industry Average Wholesale Price Litig., 230 F.R.D. 61 (D.Mass.2005) (“Pharm. I”); see also In re Pharm. Industry Average Wholesale Price Litig., 491 F.Supp.2d 20 (D.Mass.2007) (“Pharm. II”).

A. The Spread (AWP)

Each year, more than three billion prescriptions are written in the United States for approximately 65,000 drugs. The common pricing benchmark for virtually all drug reimbursement transactions during the class period was “Average Wholesale Price” (“AWP”). AWPs were compiled and published in drug pricing compendia by three publishing companies, including defendant First DataBank (“FDB”), which had a virtual monopoly as an electronic source for drug pricing information. Medispan, another publisher, received its electronic data from FDB.4

Pharmacy Benefit Managers (“PBMs”) play a critical role in the reimbursement of drugs. There are approximately 11,000 TPPs, which include large insurers like Aetna and Blue Cross-Blue Shield, and small, unsophisticated health and welfare plans, the so-called TaflAHartley Plans, which receive payments from employers under collective bargaining agreements. Nearly all TPPs contract with PBMs to assist in the reimbursement process. PBMs are the “800-[82] pound gorillas of pharmaceutical reimbursement” and their relationships with TPPs are heavily negotiated and highly individualized. See Pharm. I, at 71. TPPs negotiate drug pricing discounts with PBMs based on AWP, and PBMs negotiate discounts with the pharmacy networks based on AWP. Sometimes TPPs negotiate directly with pharmacies for reimbursement rates. Typically TPPs enter into a contract with PBMs to reimburse pharmacies at AWP minus 15 to 17 percent plus a dispensing fee. Competition among PBMs for the business of TPPs is fierce.

AWP is an artificial price, which sophisticated market participants like PBMs and larger insurers understood during the class period was not a true average of wholesale prices, or an average sales price. Historically, drug manufacturers reported the AWP to the publisher at a markup of 20% or 25% from the Wholesale Acquisition Cost (“WAC”) for branded single-source, self-administered drugs. Manufacturers typically sell drugs to wholesalers on the basis of “WAC.” Wholesalers sell drugs to retail pharmacies based on WAC plus or minus a factor that generates a margin for the wholesaler. Sometimes, manufacturers only reported a “WAC,” and then suggested the appropriate markup for the publishers to generate the AWP. Typically, the publishing company played no independent role in establishing AWP, other than applying this formulaic markup to the manufacturer’s price.

The retail distribution chain includes national chain drug pharmacies, independent pharmacies, mail order houses, and other retailers. Although retailers buy pharmaceuticals on the basis of WAC, they get reimbursed by TPPs and consumers for branded drugs based on a percentage of AWP, as described above. In this litigation, the difference between WAC, what retailers pay to acquire drugs, and what consumers and TPPs pay to the retailers for the drugs, is called the “spread.” Retailers make their profit from the spread. As the difference between AWP and WAC increases, the profit to retail and chain pharmacies like Albert-sons, Rite Aid and WalMart increases; as AWP rises the cost to payors, including those consumers who must make co-payments based on a percentage of AWP, increases as well. Although higher WAC to AWP markups made the drugs more appealing to pharmacies because they could reap a greater profit, manufacturers also had an incentive to maintain the lower markups because it gave them better treatment by managed care.

B. The Scheme

Free access — add to your briefcase to read the full text and ask questions with AI

New England Carpenters Health Benefits Fund v. First Databank, Inc., 244 F.R.D. 79, 68 Fed. R. Serv. 3d 1467, 42 Employee Benefits Cas. (BNA) 1433, 2007 U.S. Dist. LEXIS 63159, 2007 WL 2416516 (D. Mass. 2007).

244 F.R.D. 79 (New England Carpenters Health Benefits Fund v. First Databank, Inc.) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

Related

West Virginia Department of Health & Human Resources v. Sebelius
172 F. Supp. 3d 904 (S.D. West Virginia, 2016)
In re Checking Account Overdraft Litigation
307 F.R.D. 630 (S.D. Florida, 2015)
Skilstaf, Inc. v. Cvs Caremark Corp.
669 F.3d 1005 (Ninth Circuit, 2012)
San Francisco Health Plan v. McKesson Corp.
767 F. Supp. 2d 263 (D. Massachusetts, 2011)
In RE McKESSON GOVERNMENTAL ENTITIES
767 F. Supp. 2d 263 (D. Massachusetts, 2011)
Donovan v. Philip Morris USA, Inc.
268 F.R.D. 1 (D. Massachusetts, 2010)
In Re Pharm. Industry Average Wholesale Price Lit.
582 F.3d 156 (First Circuit, 2009)
New England Carpenters Health Benefits Fund v. McKesson Corp.
573 F. Supp. 2d 431 (D. Massachusetts, 2008)