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United States District Court for the Western District of Oklahoma
April 4, 2022, Decided; April 4, 2022, Filed
Case No. CIV-19-977-J
Before the Court are the parties' cross motions for summary judgment [Doc. Nos. 96 and 97] .1 The motions have been fully briefed. Based upon the parties' submissions, the Court makes its determination.2
In simple terms, health insurance plans design pharmacy benefits by determining, among other factors, what drugs are covered, where beneficiaries can obtain these drugs using their plan benefits, and any cost-sharing [**2] the plan member will be required to pay for the covered drug. The vast majority of health insurance plans providing drug benefits use a pharmacy benefit manager (PBM) to act as an intermediary in ensuring beneficiaries can use their drug benefits to obtain prescriptions. PBMs create pharmacy networks and then contract with pharmacies in those networks to provide prescriptions to beneficiaries. When a pharmacy dispenses the prescription, it then files a claim with the PBM. The PBM processes that claim and notifies the pharmacy how much the plan will pay and how much the beneficiary must pay. Afterwards, the PBM reimburses the pharmacy according to the contract between the PBM and the pharmacy. The contract between the PBM and the pharmacy determines the reimbursement rate, not the insurance plan. The PBM then bills the insurance plan according to its contract with the insurance plan, and the insurance plan pays the prescription benefit to the PBM.
Several states, including Oklahoma, have sought to regulate PBMs. In 2019, the Oklahoma Legislature passed the Oklahoma's Patient's Right to Pharmacy Choice Act (Act), Okla. Stat. tit. 36, § 6958, et seq. To compliment the Act, the Oklahoma Insurance Department enacted various [**3] regulations.
[*1207] PCMA is the national trade association for PBMs, representing sixteen PBMs. In this case, PCMA challenges the Act and the related regulations.3 Specifically, PCMA alleges the Employment Retirement Income Security Act (ERISA) and Medicare Part D preempt the Act and related regulations and claims that the regulations were adopted in violation of the Oklahoma Administrative Procedures Act (OAPA). On July 9, 2020, the Court granted in part and denied in part PCMA's motion for preliminary injunction and enjoined enforcement of Okla. Stat. tit. 36, §§ 6961(A),(D) and Okla. Admin. Code 365:25-29-7.1(a)(3). PCMA and Defendants now each move for judgment as a matter of law.
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598 F. Supp. 3d 1200 *; 2022 U.S. Dist. LEXIS 83510 **; 2022 WL 1438659
PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION, Plaintiff, v. GLEN MULREADY, in his official capacity as Insurance Commissioner of Oklahoma, and the OKLAHOMA INSURANCE DEPARTMENT, Defendants.
Prior History: Pharm. Care Mgmt. Ass'n v. Mulready, 2020 U.S. Dist. LEXIS 261290 (W.D. Okla., July 9, 2020)
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