State of Nevada v. Optum, Inc.

District Court, D. Nevada·Decided March 30, 2025·No. 2:24-cv-00493·Unknown

Opinion

* * *

State of Nevada, Case No. 2:24-cv-00493-RFB-DJA

Plaintiff, ORDER

v.

Optum, Inc et al.,

Defendants.

Before the Court is Plaintiff’s Motion to Remand to State Court. For the following reasons, the Court Grants the motion. I. PROCEDURAL HISTORY On March 12, 2024, Removing Defendant’s OptumRx, Inc., Express Scripts., ESI Mail Pharmacy Service, Inc., Express Scripts Pharmacy, Inc., and Medco Health Solutions, Inc. removed this case from the Eighth Judicial District Court to the U.S. District Court for the District of Nevada. ECF No.1. On March 15, 2024, Plaintiff filed a Motion to Remand to State Court. ECF No. 8. The motion was fully briefed on April 5, 2024. On October 22, 2024, the Court held a Motion Hearing on Plaintiff’s Motion to Remand. ECF No. 57. The Court’s Order follows. II. FACTUAL ALLEGATIONS The following facts are alleged in the operative Complaint. Plaintiff, the State of Nevada, initiated this action against Defendants to abate the public nuisance caused in part by the role of pharmacy benefit managers, inter alia, in worsening the opioid epidemic in Nevada. i. UHG/Optum Defendants Defendant United Health Group, Inc. (“UHG”) operates through two connected divisions: Optum and UnitedHealthcare. Defendant Optum, Inc. (“Optum”) is a wholly owned subsidiary of UHG. Optum manages other subsidiaries that administer UHG’s pharmacy benefits, including OptumRx, Inc. (“OptumRx”), which operates as the pharmacy benefit manager (“PBM”) for UHG. Defendants OptumInsight, Inc., OptumInsight Life Sciences, Inc., and the Lewin Group, Inc., are referred to collectively as “OptumInsight.” OptumInsight analyzed data and other information concerning opioid prescription claims data and health plans’ opioid utilization for use in its research and consulting efforts. Plaintiff alleges that UHG, OptumRx Holdings, LLC and Optum are directly involved in the conduct and control of OptumInsight’s and OptumRx’s operations, management and business decisions. Therefore, Plaintiff collectively refers to UHG, OptumRx, and OptumInsight as “UHG/Optum.” UHG/Optum is named as a Defendant in its capacity as (1) PBM, (2) data, analytics, consulting, and research provider, and (3) mail-order pharmacy. ii. ESI Defendants Defendant Evernorth Health, Inc. (“Evernorth”), formerly known as Express Scripts Holding Company, is the immediate or indirect parent of pharmacy, PBM, research/analytics subsidiaries that operate throughout Nevada. Defendant Express Scripts, Inc. (“Express Scripts”) is the immediate or indirect parent of pharmacy and PBM subsidiaries that operate throughout Nevada. Defendant Express Scripts Administrators, LLC provided the PBM services in Nevada during the relevant period. Defendant Medco Health Solutions, Inc. (“Medco”) merged with Express Scripts in 2012. Prior to the merger, Medco provided the at-issue PBM and mail-order services in Nevada. Defendant ESI Mail Pharmacy Service, Inc. is a wholly owned subsidiary of Defendant Evernorth and provided mail-order pharmacy services in Nevada. Defendant Express Scripts Pharmacy, Inc. also provided mail-order pharmacy services in Nevada. Defendant Express Scripts Specialty Distribution Services, Inc. is a wholly owned subsidiary of Evernorth and provided or assisted in providing PBM services. The State alleges that Evernorth and Express Scripts, Inc. control Express Scripts Administrators, ESI Mail Pharmacy Service, Medco, Express Scripts Pharmacy, and Express Scripts Specialty Distribution Services’ operations, management, and business decisions. Therefore, these Defendants are collectively referred to as “ESI.” The ESI Defendants are also sued in their capacity as (1) PBM, (2) data, analytics, and research provider, and (3) mail-order pharmacy. iii. Carelon Defendants Defendant Elevance Health, Inc. (“Elevance”) is the Blue Cross and Blue Shield licensee for Nevada and offers PBM services through Defendant CarelonRx, its wholly owned subsidiary. Defendant Carelon Insights, Inc., analyzes data and other information concerning opioid prescription claims data and health plans’ opioid utilization for use in its research and consulting efforts. The State alleges that Elevance controls CarelonRx and Carelon Insight, Inc.’s operations, management, and business decisions. Therefore, these Defendants are referred to collectively as “Carelon.” Carelon is named as a defendant in its capacities as a (1) PBM and (2) data, analytics, and research provider. B. Definitions Pharmacy benefit managers (PBMs) are entities hired to administer and manage prescription drug benefits on behalf of various health benefits programs, including both commercial and government programs. PBMs administer prescription drug benefits for health plans, purchase drugs from manufacturers on behalf of those plans, and negotiate payment terms for pharmacies that dispense the drugs to patients. PBMs create lists of drugs that are selected to be covered by health plans. These lists are known as “formularies.” PBM formularies are divided into tiers which establish out-of-pocket costs consumers are to pay for a chosen drug. The first tier of a PBM drug formulary will be less expensive for the consumer compared to the higher tiers. C. Allegations PBMs, such as those named as Defendants in this action, influence drug utilization by (1) placing preferred drugs on lower tiers of their formularies and (2) implementing, or failing to implement, utilization management tools which allow PBMs to (a) limit the quantity of drugs dispensed, (b) require prior authorization before dispensing specific drugs, and (c) implement “step edits” which require patients to try safer medication before progressing to more dangerous drugs. Defendants in this action incentivized their clients to adopt Defendants’ standard formularies by implementing financial consequences for deviating from them. Plaintiff alleges that by incentivizing the use of their standard formularies as well as their utilization management tools, Defendants dictated the consumer cost and any restrictions placed on prescription opioids. As a result, by way of formularies with opioids placed on lower tiers and few restrictions, Defendants ensured opioid sales to their drug manufacturer partners. In this way, Plaintiff alleges, Defendants worked to increase opioid utilization in order to maximize profit and therefore directly contributed to the dispensing of more opioid pills to individuals than were needed for legitimate medical purposes. Simultaneously, Defendants allegedly falsely represented to their clients, patients, and the public that they design drug formularies and programs in a manner that is cost effective and promotes the safe use and appropriate prescription of opioids. Additionally, Plaintiff brings claims against Defendants for failing to prevent diversion of prescription opioids into the illegal market by, inter alia, monitoring and reporting suspicious activity. Specifically, Plaintiff alleges that Defendants ESI and UHG/Optum knowingly allowed widespread diversion to occur, in violation of Nevada law, by: (1) failing to adequately use data available to them to identify doctors who were writing suspicious prescriptions; (2) failing to analyze (a) the number of opioid prescriptions filled in a geographical area relative to the population of the community, (b) the increase in opioid sales relative to past years, (c) the number of opioid prescriptions filled relative to other drugs, and (d) the increase in annual opioid sales relative to the increase in annual sales of other drugs; and (3) failing to conduct adequate internal or external audits of their opioid sales. Ultimately, Plaintiff claims that Defendants were, or should have been, fully aware that the quantity of opioids being distributed was untenable and in many areas was so high that illegal diversion was the only logical explanation, yet Defendants did not take meaningful action to investig

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State of Nevada v. Optum, Inc., (D. Nev. 2025).

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