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SUPREME COURT OF THE UNITED STATES
_________________
No. 18–540
_________________
LESLIE RUTLEDGE, ATTORNEY GENERAL OF ARKANSAS,
PETITIONER
v. PHARMA- CEUTICAL CARE MANAGEMENT
ASSOCIATION
on writ of certiorari to the united states
court of appeals for the eighth circuit
[December 10, 2020]
Justice Sotomayor delivered the opinion of the
Court.
Arkansas’ Act 900 regulates the price at which
pharmacy benefit managers reimburse pharmacies for the cost of
drugs covered by prescription-drug plans. The question presented in
this case is whether the Employee Retirement Income Security Act of
1974 (ERISA), 88Stat. 829, as amended, 29 U. S. C. §1001
et seq., pre-empts Act 900
. The Court holds that
the Act has neither an impermissible connection with nor reference
to ERISA and is therefore not pre-empted.
I
A
Pharmacy benefit managers (PBMs) are a
little-known but important part of the process by which many
Americans get their prescription drugs. Generally speaking, PBMs
serve as intermediaries between prescription-drug plans and the
pharmacies that beneficiaries use. When a beneficiary of a
prescription-drug plan goes to a pharmacy to fill a prescription,
the pharmacy checks with a PBM to determine that person’s coverage
and copayment information. After the beneficiary leaves with his or
her prescription, the PBM reimburses the pharmacy for the
prescription, less the amount of the beneficiary’s copayment. The
prescription-drug plan, in turn, reimburses the PBM.
The amount a PBM “reimburses” a pharmacy for a
drug is not necessarily tied to how much the pharmacy paid to
purchase that drug from a wholesaler. Instead, PBMs’ contracts with
pharmacies typically set reimbursement rates according to a list
specifying the maximum allowable cost (MAC) for each drug. PBMs
normally develop and administer their own unique MAC lists.
Likewise, the amount that prescription-drug plans reimburse PBMs is
a matter of contract between a given plan and a PBM. A PBM’s
reimbursement from a plan often differs from and exceeds a PBM’s
reimbursement to a pharmacy. That difference generates a profit for
PBMs.
In 2015, Arkansas adopted Act 900 in response to
concerns that the reimbursement rates set by PBMs were often too
low to cover pharmacies’ costs, and that many pharmacies,
particularly rural and independent ones, were at risk of losing
money and closing. 2015 Ark. Acts no. 900. In effect, Act 900
requires PBMs to reimburse Arkansas pharmacies at a price equal to
or higher than that which the pharmacy paid to buy the drug from a
wholesaler.
Act 900 accomplishes this result through three
key enforcement mechanisms. First, the Act requires PBMs to tether
reimbursement rates to pharmacies’ acquisition costs by timely
updating their MAC lists when drug wholesale prices increase. Ark.
Code Ann. §17–92–507(c)(2) (Supp. 2019). Second, PBMs must provide
administrative appeal procedures for pharmacies to challenge MAC
reimbursement prices that are below the pharmacies’ acquisition
costs. §17–92–507(c)(4)(A)(i)(
b). If a pharmacy could not
have acquired the drug at a lower price from its typical
wholesaler, a PBM must increase its reimbursement rate to cover the
pharmacy’s acquisition cost. §17–92–507(c)(4)(C)(i)(
b). PBMs
must also allow pharmacies to “reverse and rebill” each
reimbursement claim affected by the pharmacy’s inability to procure
the drug from its typical wholesaler at a price equal to or less
than the MAC reimbursement price. §17–92–507(c)(4)(C)(iii). Third,
and finally, the Act permits a pharmacy to decline to sell a drug
to a beneficiary if the relevant PBM will reimburse the pharmacy at
less than its acquisition cost. §17–92–507(e).
B
Respondent Pharmaceutical Care Management
Association (PCMA) is a national trade association representing the
11 largest PBMs in the country. After the enactment of Act 900,
PCMA filed suit in the Eastern District of Arkansas, alleging, as
relevant here, that Act 900 is pre-empted by ERISA. See 29
U. S. C. §1144(a) (ERISA pre-empts “any and all State
laws insofar as they may now or hereafter relate to any employee
benefit plan”).
Before the District Court issued its opinion in
response to the parties’ cross-motions for summary judgment, the
Court of Appeals for the Eighth Circuit decided, in a different
case, that ERISA pre-empts a similar Iowa statute.
Pharmaceutical Care Mgmt. Assn. v.
Gerhart, 852 F.3d
722 (2017). The Eighth Circuit concluded that the Iowa statute was
pre-empted for two reasons. First, it made “implicit reference” to
ERISA by regulating PBMs that administer benefits for ERISA plans.
Id., at 729. Second, it was impermissibly “connected with”
an ERISA plan because, by requiring an appeal process for
pharmacies to challenge PBM reimbursement rates and restricting the
sources from which PBMs could determine pricing, the law limited a
plan administrator’s ability to control the calculation of drug
benefits.
Id., at 726, 731. Concluding that Arkansas’ Act
900 contains similar features, the District Court held that ERISA
likewise pre-empts Act 900. 240 F. Supp. 3d 951, 958 (ED Ark.
2017). The Eighth Circuit affirmed. 891 F.3d 1109, 1113 (2018).
This Court granted certiorari. 589 U. S. ___ (2020).
II
ERISA pre-empts “any and all State laws
insofar as they may now or hereafter relate to any employee benefit
plan” covered by ERISA. 29 U. S. C. §1144(a). “[A] state
law relates to an ERISA plan if it has a connection with or
reference to such a plan.”
Egelhoff v.
Egelhoff,
532
U.S. 141, 147 (2001) (internal quotation marks omitted).
Because Act 900 has neither of those impermissible relationships
with an ERISA plan, ERISA does not pre-empt it.
A
To determine whether a state law has an
“impermissible connection” with an ERISA plan, this Court considers
ERISA’s objectives “as a guide to the scope of the state law that
Congress understood would survive.”
California Div. of Labor
Standards Enforcement v.
Dillingham Constr., N. A.,
Inc.,
519 U.S.
316, 325 (1997) (internal quotation marks omitted). ERISA was
enacted “to make the benefits promised by an employer more secure
by mandating certain oversight systems and other standard
procedures.”
Gobeille v.
Liberty Mut. Ins. Co., 577
U.S. 312, 320–321 (2016). In pursuit of that goal, Congress sought
“to ensure that plans and plan sponsors would be subject to a
uniform body of benefits law,” thereby “minimiz[ing] the
administrative and financial burden of complying with conflicting
directives” and ensuring that plans do not have to tailor
substantive benefits to the particularities of multiple
jurisdictions.
Ingersoll-Rand Co. v.
McClendon,
498 U.S.
133, 142 (1990).
ERISA is therefore primarily concerned with pre-
empting laws that require providers to structure benefit plans in
particular ways, such as by requiring payment of specific benefits,
Shaw v.
Delta Air Lines, Inc.,
463 U.S.
85 (1983), or by binding plan administrators to specific rules
for determining beneficiary status,
Egelhoff,
532 U.S.
141. A state law may also be subject to pre-emption if “acute,
albeit indirect, economic effects of the state law force an ERISA
plan to adopt a certain scheme of substantive coverage.”
Gobeille, 577 U. S., at 320 (internal quotation marks
omitted). As a shorthand for these considerations, this Court asks
whether a state law “governs a central matter of plan
administration or interferes with nationally uniform plan
administration.”
Ibid. (internal quotation marks and
ellipsis omitted). If it does, it is pre-empted.
Crucially, not every state law that affects an
ERISA plan or causes some disuniformity in plan administration has
an impermissible connection with an ERISA plan. That is especially
so if a law merely affects costs. In
New York State Conference
of Blue Cross & Blue Shield Plans v.
Travelers Ins.
Co.,
514 U.S.
645 (1995), this Court addressed a New York law that imposed
surcharges of up to 13% on hospital billing rates for patients
covered by insurers other than Blue Cross/Blue Shield (Blues).
Plans that bought insurance from the Blues therefore paid less for
New York hospital services than plans that did not. This Court
presumed that the surcharges would be passed on to insurance
buyers, including ERISA plans, which in turn would incentivize
ERISA plans to choose the Blues over other alternatives in New
York.
Id., at 659. Nevertheless, the Court held that such an
“indirect economic influence” did not create an impermissible
connection between the New York law and ERISA plans because it did
not “bind plan administrators to any particular choice.”
Ibid. The law might “affect a plan’s shopping decisions, but
it [did] not affect the fact that any plan will shop for the best
deal it can get.”
Id., at 660. If a plan wished, it could
still provide a uniform interstate benefit package.
Ibid.
In short, ERISA does not pre-empt state rate
regulations that merely increase costs or alter incentives for
ERISA plans without forcing plans to adopt any particular scheme of
substantive coverage.
Id., at 668; cf.
De Buono v.
NYSA–ILA Medical and Clinical Services Fund,
520 U.S.
806, 816 (1997) (concluding that ERISA did not pre-empt a state
tax on gross receipts for patient services that simply increased
the cost of providing benefits);
Dillingham, 519 U. S.,
at 332 (holding that ERISA did not pre-empt a California statute
that incentivized, but did not require, plans to follow certain
standards for apprenticeship programs).
The logic of
Travelers decides this case.
Like the New York surcharge law in
Travelers, Act 900 is
merely a form of cost regulation. It requires PBMs to reimburse
pharmacies for prescription drugs at a rate equal to or higher than
the pharmacy’s acquisition cost. PBMs may well pass those increased
costs on to plans, meaning that ERISA plans may pay more for
prescription-drug benefits in Arkansas than in, say, Arizona. But
“cost uniformity was almost certainly not an object of
pre-emption.”
Travelers, 514 U. S., at 662. Nor is the
effect of Act 900 so acute that it will effectively dictate plan
choices. See
id., at 668. Indeed, Act 900 is less intrusive
than the law at issue in
Travelers, which created a
compelling incentive for plans to buy insurance from the Blues
instead of other insurers. Act 900, by contrast, applies equally to
all PBMs and pharmacies in Arkansas. As a result, Act 900 does not
have an impermissible connection with an ERISA plan.
B
Act 900 also does not “refer to” ERISA. A law
refers to ERISA if it “ ‘acts immediately and exclusively upon
ERISA plans or where the existence of ERISA plans is essential to
the law’s operation.’ ”
Gobeille, 577 U. S., at
319–320 (quoting
Dillingham, 519 U. S., at 325;
ellipsis omitted).
Act 900 does not act immediately and exclusively
upon ERISA plans because it applies to PBMs whether or not they
manage an ERISA plan. Indeed, the Act does not directly regulate
health benefit plans at all, ERISA or otherwise. It affects plans
only insofar as PBMs may pass along higher pharmacy rates to plans
with which they contract.
ERISA plans are likewise not essential to Act
900’s operation. Act 900 defines a PBM as any “entity that
administers or manages a pharmacy benefits plan or program,” and it
defines a “pharmacy benefits plan or program,” in turn, as any
“plan or program that pays for, reimburses, covers the cost of, or
otherwise provides for pharmacist services to individuals who
reside in or are employed in [Arkansas].” Ark. Code Ann.
§§17–92–507(a)(7), (9). Under those provisions, Act 900 regulates
PBMs whether or not the plans they service fall within ERISA’s
coverage.[
1] Act 900 is
therefore analogous to the law in
Travelers, which did not
refer to ERISA plans because it imposed surcharges “regardless of
whether the commercial coverage [was] ultimately secured by an
ERISA plan, private purchase, or otherwise.” 514 U. S., at
656; see also
Dillingham, 519 U. S., at 328 (concluding
that the relevant California law did not refer to ERISA plans
because the apprenticeship programs it regulated did not need to be
ERISA programs).
III
PCMA disagrees that Act 900 amounts to nothing
more than cost regulation. It contends that Act 900 has an
impermissible connection with an ERISA plan because its enforcement
mechanisms both directly affect central matters of plan
administration and interfere with nationally uniform plan
administration. The mechanisms that PCMA identifies, however, do
not require plan administrators to structure their benefit plans in
any particular manner, nor do they lead to anything more than
potential operational inefficiencies.[
2]
PCMA first claims that Act 900 affects plan
design by mandating a particular pricing methodology for pharmacy
benefits. As PCMA reasons, while a plan might prefer that PBMs
reimburse pharmacies using a MAC list constructed with an eye
toward containing costs and ensuring predictability, Act 900
ignores that preference and instead requires PBMs to reimburse
pharmacies based on acquisition costs. But that argument is just a
long way of saying that Act 900 regulates reimbursement rates.
Requiring PBMs to reimburse pharmacies at or above their
acquisition costs does not require plans to provide any particular
benefit to any particular beneficiary in any particular way. It
simply establishes a floor for the cost of the benefits that plans
choose to provide. The plans in
Travelers might likewise
have preferred that their insurers reimburse hospital services
without paying an additional surcharge, but that did not transform
New York’s cost regulation into central plan
administration.[
3]
Act 900’s appeal procedure likewise does not
govern central matters of plan administration. True, plan
administrators must “comply with a particular process, subject to
state-specific deadlines, and [Act 900] dictates the substantive
standard governing the resolution of [an] appeal.” Brief for
Respondent 24. Moreover, if a pharmacy wins its appeal, a plan,
depending on the terms of its contract with a PBM, may need to
recalculate and reprocess how much it (and its beneficiary) owes.
But any contract dispute implicating the cost of a medical benefit
would involve similar demands and could lead to similar results.
Taken to its logical endpoint, PCMA’s argument would pre-empt any
suits under state law that could affect the price or provision of
benefits. Yet this Court has held that ERISA does not pre-empt
“state-law mechanisms of executing judgments against ERISA welfare
benefit plans, even when those mechanisms prevent plan participants
from receiving their benefits.”
Mackey v.
Lanier
Collection Agency & Service, Inc.,
486
U.S. 825, 831–832 (1988).
PCMA also argues that Act 900 interferes with
central matters of plan administration by allowing pharmacies to
decline to dispense a prescription if the PBM’s reimbursement will
be less than the pharmacy’s cost of acquisition. PCMA contends that
such a refusal effectively denies plan beneficiaries their
benefits, but that argument misunderstands the statutory scheme.
Act 900 requires PBMs to compensate pharmacies at or above their
acquisition costs. When a pharmacy declines to dispense a
prescription, the responsibility lies first with the PBM for
offering the pharmacy a below-acquisition reimbursement.
Finally, PCMA argues that Act 900’s enforcement
mechanisms interfere with nationally uniform plan administration by
creating “operational inefficiencies.” Brief for Respondent 34. But
creating inefficiencies alone is not enough to trigger ERISA
pre-emption. See,
e.g., Mackey, 486 U. S., at
831 (holding that ERISA did not pre-empt a state garnishment
procedure despite petitioners’ contention that such actions would
impose “substantial administrative burdens and costs” on plans).
PCMA argues that those operational inefficiencies will lead to
increased costs and, potentially, decreased benefits. ERISA does
not pre-empt a state law that merely increases costs, however, even
if plans decide to limit benefits or charge plan members higher
rates as a result. See
De Buono, 520 U. S., at 816
(“Any state tax, or other law, that increases the cost of providing
benefits to covered employees will have some effect on the
administration of ERISA plans, but that simply cannot mean that
every state law with such an effect is pre-empted by the federal
statute”).
* * *
In sum, Act 900 amounts to cost regulation
that does not bear an impermissible connection with or reference to
ERISA. The judgment of the Eighth Circuit is therefore reversed,
and the case is remanded for further proceedings consistent with
this opinion.
It is so ordered.
Justice Barrett took no part in the
consideration or decision of this case.