323 F. Supp. 3d 501
S.D. Ill.2018Background
- Rebecca Weinreb, a Plan beneficiary, suffers from Global Diffuse Adenomyosis (GDA), a painful, female-only condition; her physician prescribed fentanyl formulations after other opioids failed.
- Xerox/Conduent's self-funded Health and Welfare Plan used Medco (2009–2014) then Caremark as pharmacy administrator; Caremark exercised discretionary authority under the Plan to grant prior authorizations.
- Caremark changed prior-authorization approvals in 2014, limiting or denying fentanyl (Actiq, Fentora, Subsys) on the ground that the Plan’s clinical guidelines cover fentanyl only for FDA‑approved, on‑label management of breakthrough cancer pain.
- Plaintiffs exhausted internal appeals; Caremark denied coverage citing the Plan’s definition of “medically necessary” and its clinical guidelines restricting fentanyl to cancer-related pain.
- Plaintiffs sued under ERISA § 502(a)(1)(B), Title VII, the Pregnancy Discrimination Act (PDA), the Equal Pay Act (EPA), and Section 1557 of the Affordable Care Act (ACA); Defendants moved to dismiss.
- The district court dismissed all claims with prejudice: ERISA claims because Caremark applied clear Plan terms (arbitrary-and-capricious review); Title VII/PDA, EPA, and ACA claims for failure to plead sex‑based intentional discrimination or required factual support.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| ERISA: whether denial of fentanyl benefits was arbitrary and capricious | Weinreb: prior approvals and medical necessity (off‑label use) should require coverage; denial was improper | Caremark/Plan: Plan and clinical guidelines limit fentanyl to on‑label cancer use; administrator acted under discretionary authority | Denial upheld; administrator applied unambiguous Plan terms; ERISA claim dismissed with prejudice |
| Title VII / PDA: whether Plan discriminates on basis of sex or pregnancy | Weinreb: Plan's application yields unequal benefits tied to sex because GDA affects only women; alleged disparate treatment of male employee with female spouse | Employer: policy is facially neutral (cancer vs non‑cancer); no discriminatory intent or disparate impact pleaded | Dismissed with prejudice for failing to plead discriminatory intent or statistical disparate impact |
| Equal Pay Act: whether fringe‑benefit disparity constitutes EPA violation | Weinreb: male employee (David) denied same comprehensive spouse coverage as female employees | Employer: EPA requires showing substantially equal jobs and wage disparity between employees; plaintiffs allege no job‑content comparators | Dismissed with prejudice for failure to plead prima facie EPA claim (no comparator or job‑content allegations) |
| ACA §1557 (Title IX standard): whether denial constitutes sex discrimination under ACA | Weinreb: Caremark’s rule disproportionately harms females (GDA is female‑only) and thus discriminates on basis of sex | Caremark: §1557 incorporates Title IX — requires intentional discrimination; plaintiffs plead only conclusory disparate‑impact allegations | Dismissed with prejudice for failing to plead intentional, motivating discrimination under Title IX standards |
Key Cases Cited
- Bell Atl. Corp. v. Twombly, 550 U.S. 544 (standard for plausibility pleading)
- Ashcroft v. Iqbal, 556 U.S. 662 (legal conclusions not entitled to assumption of truth)
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (ERISA review: de novo absent discretionary authority)
- Curtiss‑Wright Corp. v. Schoonejongen, 514 U.S. 73 (ERISA does not vest welfare benefits; employers may amend/terminate plans)
- Pegram v. Herdrich, 530 U.S. 211 (ERISA does not mandate specific welfare benefits)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (plan documents control; courts need not give special weight to treating physicians)
- Krauss v. Oxford Health Plans, Inc., 517 F.3d 614 (2d Cir. 2008) (administrator discretion -> arbitrary‑and‑capricious standard)
- Celardo v. GNY Auto. Dealers Health & Welfare Trust, 318 F.3d 142 (2d Cir. 2003) (scope of review under arbitrary‑and‑capricious standard)
- Saks v. Franklin Covey Co., 316 F.3d 337 (2d Cir. 2003) (PDA analysis re: policies affecting men and women equally)