Omnicare, Inc. v. Unitedhealth Group, Inc.

629 F.3d 697, 2011 U.S. App. LEXIS 495, 2011 WL 61649
CourtCourt of Appeals for the Seventh Circuit
DecidedJanuary 10, 2011
Docket09-1152
StatusPublished
Cited by557 cases

This text of 629 F.3d 697 (Omnicare, Inc. v. Unitedhealth Group, Inc.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Omnicare, Inc. v. Unitedhealth Group, Inc., 629 F.3d 697, 2011 U.S. App. LEXIS 495, 2011 WL 61649 (7th Cir. 2011).

Opinion

TINDER, Circuit Judge.

In the months leading up to the 2006 launch of Medicare Part D, institutional pharmacy Omnicare entered into separate service contracts with merging Medicare Part D plan sponsors UnitedHealth Group and PacifiCare. The terms of the United-Health Group contract were favorable to Omnicare; the terms of the PacifiCare contract, which Omnicare signed without negotiation, were significantly less so. Shortly after the UnitedHealth Group-PacifiCare merger was finalized, United-Health Group abandoned its contract with Omnicare and joined PacifiCare’s. Omnicare cried foul and filed a Sherman Act claim, alleging that UnitedHealth Group and PacifiCare conspired to depress the rate of reimbursement it would receive. It also raised a host of additional claims, including state antitrust claims and common law fraud, conspiracy to commit fraud and unjust enrichment claims. The district court granted summary judgment to the insurers and denied Omnicare’s cross motion for partial summary judgment. Omnicare appeals, and we affirm.

I. Background

Plaintiff-appellant Omnicare is the nation’s largest institutional pharmacy. It provides pharmaceutical services to long-term care facilities, such as nursing homes, in 47 states. Defendant-appellee United-Health Group (“United”) is a large national provider of health insurance. It acquired defendant-appellee PacifiCare, a smaller, California-based health insurer, on December 20, 2005. As part of that acquisition, United also became the owner of PacifiCare’s wholly owned subsidiary, defendant-appellee RxSolutions, a “pharmacy benefits manager” (“PBM”) that negotiates contracts with pharmacies and processes claims from plan members. See In re Pharmacy Benefit Managers Antitrust Litig., 582 F.3d 432, 434 (3d Cir.2009) (describing PBMs).

United and PacifiCare began their merger talks in early 2005, while each was developing an individual Medicare Part D plan proposal. Medicare Part D, a new government-subsidized prescription drug program for seniors and disabled individuals, was scheduled to “go live” on January 1, 2006, and the Centers for Medicare and Medicaid Services (“CMS”) required private insurers to submit their plan proposals for consideration by August 1, 2005. *700 Insurers whose plans were approved would be permitted to enter into contracts with CMS and begin providing benefits to Medicare Part D enrollees in January 2006. Before their plans could be approved, plan sponsors had to demonstrate to CMS that they had in place pharmacy networks capable of serving their anticipated enrollees. To assemble these networks, which had to include enough retail and institutional pharmacies to provide “convenient access” for enrollees, including Medicaid-eligible individuals who would be randomly assigned to Part D plans in late 2005, plan sponsors had to negotiate reimbursement contracts with numerous pharmacies. Both United and PacifiCare were negotiating contracts with Omnieare during the period of due diligence preceding their merger.

PacifiCare employed its in-house PBM RxSolutions to conduct its negotiations with Omnieare. By all accounts the negotiations did not proceed smoothly. In early June 2005, RxSolutions sent to Omnicare a copy of PacifiCare’s “any willing provider” contract, a form contract that CMS required Part D plan sponsors to develop and make available to any pharmacy willing to sign it. Omnieare in turn sent RxSolutions its own form contract, which included eighteen “Patient Protections” that Omnieare developed to address the special needs of long-term care patients. Omnieare and RxSolutions attempted to negotiate, but because each insisted on using its own form contract as the starting point they never made it out of the gate. By mid-July, eight days after United and PacifiCare signed their formal merger agreement, negotiations between Omnieare and PacifiCare broke down completely when PacifiCare, citing price concerns, walked away from the table. Omnieare assured PacifiCare that it would “stand ready to negotiate,” but PacifiCare eschewed Omnicare’s overtures and submitted its Part D bid to CMS without Omnieare in its pharmacy network. After its application was rejected, PacifiCare reopened negotiations with other pharmaceutical service providers, including Omnicare’s competitor Managed Healthcare Associates, Inc., to remedy deficiencies in its pharmacy network. PacifiCare secured CMS approval for its Part D plan in September 2005 without Omnieare in its network.

United also enlisted the assistance of a PBM, Walgreens Health Initiatives (“WHI”), to negotiate with Omnieare on its behalf. After some back-and-forth over reimbursement rates, WHI and Omnicare were able to agree on a contract under which Omnieare would provide pharmaceutical services to United’s Part D enrollees who lived in Omnicare-eontracted long-term care facilities. United, to whom the enrollees would pay their premiums, would then reimburse Omnicare at a rate of AWP-12% plus a fixed dispensing fee per prescription filled. 1 *701 This reimbursement rate was comparable to the rates Omnicare negotiated with most other health insurers. The UnitedOmnicare contract, which was executed on July 29, 2005, included Omnicare’s eighteen “Patient Protections.” United submitted its bid to CMS, with Omnicare in its pharmacy network, and received approval to operate an extensive Part D plan. Shortly after signing its contract with Omnicare and securing CMS approval, however, United enlisted outside counsel to advise it on the legality of the “Patient Protections” and other Omnicare-engineered provisions in the contract. It did not apprise Omnicare of its concerns and expressly forbade its PBM from doing so.

While the Part D network negotiations and proposal developments were winding down, the merger between United and PacifiCare was picking up. Both insurers had due diligence teams in place, and by early June 2005, the teams were meeting regularly to discuss a variety of topics, including PacifiCare’s plans for its Part D program. United tried to assuage its concerns about PacifiCare’s Part D readiness by giving PacifiCare a list of “Part D Questions” to answer. In its responses, PacifiCare revealed that its expected reimbursement rate for network pharmacies was AWP-16%. PacifiCare also provided United with a copy of its standard “any willing provider” form contract.

An actuary employed by a United affiliate met with PacifiCare representatives in early July 2005 to discuss the potential financial risks associated with Part D. At the meeting, PacifiCare disclosed its projected national average bids for its Part D plans. The actuary in turn provided, in a sealed envelope that was addressed to a PacifiCare executive who was not present, corresponding information concerning United’s projected Part D plans. Following the meeting, the actuary prepared a written summary of the actuarial risks associated with PacifiCare’s projected Part D strategy and then disqualified himself from further Part D involvement. United’s board approved the acquisition in short order after being briefed on the actuary’s summary, and PacifiCare and United executed a formal merger agreement on July 6, 2005.

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629 F.3d 697, 2011 U.S. App. LEXIS 495, 2011 WL 61649, Counsel Stack Legal Research, https://law.counselstack.com/opinion/omnicare-inc-v-unitedhealth-group-inc-ca7-2011.