GOVERNMENT OF PUERTO RICO v. EXPRESS SCRIPTS, INC.; CAREMARKPCS HEALTH, LLC; and CAREMARK PUERTO RICO, LLC
No. 23-1612
No. 23-1613
United States Court of Appeals For the First Circuit
October 18, 2024
Gelpí, Thompson, and Montecalvo, Circuit Judges.
APPEALS FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF PUERTO RICO [Hon. Jay A. García-Gregory, U.S. District Judge]
A. Joshua Podoll, with whom Enu Mainigi, Craig Singer, Williams & Connolly LLP, Eduardo A. Zayas-Marxuach, and McConnell Valdés LLC were on brief, for appellants CaremarkPCS Health, LLC, and Caremark Puerto Rico, LLC.
The Government of Puerto Rico (“the Commonwealth“) sued pharmaceutical benefit managers (“PBMs“) including Express Scripts, Inc. (“Express Scripts“), CaremarkPCS Health, LLC, and Caremark Puerto Rico, LLC, (“Caremark,” together with Express Scripts, “PBM Defendants“), and several pharmaceutical manufacturers1 in the Commonwealth of Puerto Rico Court of First Instance (“Court of First Instance“). The Commonwealth alleges that the PBM Defendants schemed to unlawfully inflate insulin prices through rebate negotiations and price setting. The PBM Defendants removed to federal court under
This appeal presents a novel issue in our circuit. So far, the courts to consider the issue as it relates to these PBM Defendants have reached different conclusions. Compare California v. CaremarkPCS Health LLC, No. 23-55597, 2024 WL 3770326, at *1 (9th Cir. Aug. 13, 2024) (mem.) (concluding that, in a dispute between California and these PBM Defendants concerning similar conduct, a similar disclaimer did “not necessarily defeat removal“), and Hawai‘i ex rel. Lopez v. CaremarkPCS Health, LLC, No. 23-464, 2024 WL 1907396, at *6-14 (D. Haw. May 1, 2024) (concluding that Hawai‘i‘s disclaimer did not prevent Caremark from satisfying
I. BACKGROUND
To set the stage, we outline the pharmaceutical industry, recount the proceedings below, and, along the way, summarize the parties’ allegations.
A. Pharmaceutical Industry Basics
There are a few key players in the pharmaceutical industry. There are pharmaceutical manufacturers, who research, develop, and sell prescription drugs at a certain list price. Of
As relevant here, PBMs create drug formularies -- lists of prescription drugs that health plans cover and to which PBMs designate tiers according to how much consumers owe for a co-payment. For example, a tier-1 drug would require a $5 co-payment, while a tier-2 drug would require a $10 co-payment, and so on. Drugs excluded from a PBM‘s formulary must be purchased out-of-pocket by consumers, making them a less desirable option in the marketplace.
Manufacturers accordingly work to ensure that PBMs include their drugs on formularies. Among other incentives, manufacturers pay rebates -- post-sale discounts calculated based on how many consumers fill a prescription for the manufacturers’ drug -- and other fees to PBMs, which in turn keep a portion of the rebates and fees before passing off the remainder to health
B. Procedural History
i. Initial Lawsuit
The Commonwealth sued in the Court of First Instance on January 17, 2023. Its four claims under the Puerto Rican Fair Competition Act,
Central to the Commonwealth‘s claims are the PBM Defendants’ rebate negotiations. The Commonwealth alleges that, since 2014, the PBM Defendants excluded certain drugs from their formularies to increase competition and encourage drug companies to offer higher rebates. The Commonwealth, in other words, accuses the PBM Defendants of effectively using their leverage as formulary holders to “sell” that “formulary space to the highest bidding drug company.” To keep up with the rising costs of formulary space, drug manufacturers in turn had to increase the WAC price. Those increased costs, the Commonwealth asserts, were then passed on to the consumers: Because “[m]any consumers’ out-of-pocket payments for insulin are tied to the WAC price, . . . consumers’ out-of-pocket payments increase when the WAC price increases.” And as a result of the jockeying and negotiating between PBMs and pharmaceutical manufacturers, consumers who use insulin are forced to switch medications every few years.
At bottom, the Commonwealth alleges that, despite the PBM Defendants’ claims that their rebate practices are helping consumers, the PBM Defendants are in fact focused on something else: receiving a higher rebate for themselves. Indeed, the Commonwealth asserts, the PBM Defendants often choose to include on their formularies the drugs for which they received the highest
The Commonwealth seeks to enjoin the PBM Defendants from engaging in any future unfair and deceptive practices related to this alleged scheme. The Commonwealth also seeks restitution, payable to any Commonwealth resident consumer affected by those practices, along with damages to the Commonwealth in the amount resulting from increased insulin prices from the scheme.
Crucial to the instant appeal is the following disclaimer, which the Commonwealth included in its complaint:
The [Commonwealth] is not seeking relief relating to any federal program (e.g., Medicaid, Medicare) or any contract related to a federal program. Moreover, the [Commonwealth‘s] claims do not arise out of a written contract, but rather are based on the larger unfair and deceptive scheme that violates the Fair Competition Act and increased prices and reduced access to insulin products for Puerto Rico consumers.
On March 17, 2023, the PBM Defendants removed under
ii. Caremark
Caremark premises removal on its obligations to carriers that provide health-insurance benefits to federal government employees through the Federal Employees Health Benefits Act of 1959 (“FEHBA“),
“OPM has direct and extensive control over these benefits contracts under the FEHBA.” Goncalves ex rel. Goncalves v. Rady Children‘s Hosp. San Diego, 865 F.3d 1237, 1246 (9th Cir. 2017) (citation omitted). And OPM‘s standard form contracts assume that PBMs will contract with FEHBA carriers and receive rebates. Off. Of Pers. Mgmt., Federal Employees Health Benefits Program Standard Contract for Experience-Rated Health Maintenance Organization Carriers I-18-I-20 (2019) (“FEHB Standard Contract“), https://perma.cc/7EX7-26DB (last visited Sept. 26, 2024). OPM thus requires FEHBA carriers to impose certain provisions in their contracts with PBMs concerning rebates, and PBMs must adhere to these provisions.2 Id. These include:
- submitting quarterly and annual reports concerning negotiated rebates;
using “pass-through transparent pricing based on the PBM‘s cost for drugs . . . in which the [FEHBA] Carrier receives the value of the PBM‘s negotiated . . . rebates“; - crediting carriers “either as a price reduction or by cash refund the value all [rebates] properly allocated to the Carrier“; and
- providing OPM with certain information upon request -- such as the PBM‘s contracts with pharmacies, manufacturers, and third parties concerning the sales of claims data.
Id. at I-17-I-19.
Caremark removed because it claims that the Commonwealth‘s lawsuit challenges its performance for FEHBA plans under the FEHBA benefits contracts. Caremark reasons that the Commonwealth, by seeking to recover for every Commonwealth resident who purchased insulin at inflated prices, necessarily seeks to recover for its residents who are federal employees who receive benefits through FEHBA. That is, Commonwealth residents who are federal employees bought insulin using health care benefits from FEHBA carriers, and Caremark collected manufacturer payments -- subject to the contractual obligations listed above.
Caremark also points out that it does not distinguish between FEHBA and non-FEHBA clients during negotiations with manufacturers for rebates -- the rebates were, and still are, negotiated on behalf of all clients. These joint negotiations have led to “rebate agreements” between Caremark and the manufacturer. Caremark reiterates that, from 2014 to the present,
Accordingly, because the Commonwealth‘s complaint sought relief for Commonwealth residents arising from Caremark‘s actions and rebate negotiations on behalf of FEHBA plans, Caremark invokes The Commonwealth moved to remand. It argued that its disclaimer eliminates any “legal basis for federal officer The district court remanded based on that disclaimer. The district court deduced that, because the Commonwealth‘s disclaimer limits its potential recovery to harms stemming from the PBM Defendants’ actions for non-federal programs and contracts, the PBM Defendants cannot claim that they acted under a federal officer‘s authority for their non-federal PBM services. It, furthermore, rejected the PBM Defendants’ indivisibility arguments “because relief would be strictly limited to non-federal health insurance plans.” And it cautioned that accepting the PBM Defendants’ argument would mean that parties that work on behalf of private and federal entities could remove even if their federal work were not at issue. Furthermore, the district court was “not persuaded that dividing the work done by [the PBM] Defendants on behalf of the federal government from the work done for its private clients [was] not possible in this case.” PBM Defendants appealed.3 We have jurisdiction under “We review de novo the district court‘s jurisdictional determination on removal. Where the district court resolves disputed issues of fact, we review those factual findings for clear error.” Moore, 25 F.4th at 34 (citations omitted). In reviewing a ruling on a motion to remand, we ask “whether federal jurisdiction exist[ed]” as “cabined by the notice of removal.” López-Muñoz, 754 F.3d at 4 (first citing BIW Deceived v. Local S6, Indus. Union of Marine & Shipbuilding Workers, 132 F.3d 824, 830 (1st Cir. 1997); and then citing Ervast v. Flexible Prods. Co., 346 F.3d 1007, 1012 n.4 (11th Cir. 2003)). Accordingly, the removing parties bear the burden of showing federal officer jurisdiction as pleaded in their notice of removal. See Moore, 25 F.4th at 34; Ervast, 346 F.3d at 1012 n.4. In reviewing whether the removing party met its burden, Courts must “credit” that party‘s “theory of the case” for why removal under Section As we mentioned above, if a single defendant properly removes under To avail itself of “The words ‘acting under’ are broad,” and, like the rest of the statute, “must be ‘liberally construed.‘” Watson, 551 U.S. at 147 (quoting Symes, 286 U.S. at 517). “‘[A]cting under’ a federal officer . . . contemplate[s] a relationship where the private party engages in an effort ‘to assist, or to help carry out, the duties or tasks of the federal superior‘” and “typically involves ‘subjection, guidance, or control.‘” Moore, 25 F.4th at 34 n.3 (quoting Watson, 551 U.S. at 151-52). For example, a The defendant must also carry out the charged conduct “‘for or relating to’ the asserted official authority.” Moore, 25 F.4th at 34. “Relating to,” as it is used in To prevent a defendant from removing under the federal officer removal statute, plaintiffs often disclaim in their complaint claims that would serve as the basis for removal.6 See St. Charles Surgical Hosp. v. La. Health Serv. & Indem. Co., 990 The federal district courts that have analyzed this “disclaimer doctrine” in detail generally distinguish between two categories of § 1442(a)(1) disclaimers: (1) “express disclaimers of the claims that serve as the grounds for removal“; and (2) mere “artful pleading for purposes of circumventing federal officer jurisdiction.” Dougherty v. A O Smith Corp., No. 13-1972, 2014 WL 3542243, at *10 (D. Del. July 16, 2014); see St. Charles Surgical Hosp., 990 F.3d at 451. To defeat removal, an express disclaimer must “explicitly renounce[] claims” “upon which federal officer removal Thus, disclaimers that “clearly carve[] out certain factual bases, whether by time span or location, such that any alleged injury could not have happened under the direction of a Distinct from express disclaimers are those that amount to “artful pleading.” These disclaimers are never credited and come in a few varieties. First, there are those in which “the ‘applicability [of the disclaimer] turns on the core question of whether a defendant‘s alleged [unlawful behavior] was required or caused by their relationship with the federal government.‘” Healthcare Venture Partners, LLC v. Anthem Blue Cross & Blue Shield, No. 1:21-cv-29, 2021 WL 5194662, at *7 (S.D. Ohio Nov. 8, 2021) (quoting Martincic v. A.O. Smith Corp., No. 2:20-cv-958, 2020 WL 5850317, at *3 (W.D. Pa. Oct. 1, 2020)). These disclaimers are considered “circular” because, if permitted, they would “force Second, and equally as ineffective, are waivers that “disavow[] claims based on a defendant‘s acts or omissions carried out under color of office, but the plaintiff, nonetheless, s[eeks] to recover based on a defendant‘s official acts.” Batchelor, 185 F. Supp. 3d at 1363 (citations omitted). These disclaimers serve as an attempted end run around the federal officer removal statute, “depriv[ing] the federal officer of the right” to have their immunity litigated in federal court. In re Asbestos Prods. Liab. Litig. (No. VI), 770 F. Supp. 2d 736, 740-42 (E.D. Pa. 2011) (declaring ineffective a disclaimer excluding claims “caused by the acts or omissions of defendants committed at the specific and proven direction of an officer of the United States government acting in his official capacity” because “the only claims alleged against Defendant arise[] from exposure on U.S. Naval ships at As we previewed above, we consider whether the disclaimer in the Commonwealth‘s complaint prevented Caremark from removing under § 1442(a)(1).7 The Commonwealth argues that its The Commonwealth‘s complaint disclaimed any “relief relating to any federal program . . . or any contract related to a federal program.” The district court found this valid because it purportedly limited the Commonwealth‘s recovery to non-federal programs, a swath of claims that, the district court believed, would not require a state court to adjudicate whether the PBM Defendants acted on behalf of a federal officer. So, the district court concluded, the PBM Defendants could not claim that their In reaching this conclusion, the district court disagreed with Caremark that it was “not possible” to divide its services between whether they were for the federal government or non-federal healthcare plans. However, the indivisibility of those services is an important facet of Caremark‘s “theory of the case” that must be “credit[ed]” in evaluating removal. Acker, 527 U.S. at 432. Under the federal officer removal statute, a federal court examines the notice of removal‘s well-pleaded allegations to see if the removing party has demonstrated “an adequate threshold showing” for removal. Id. Part of that task includes “credit[ing]” that party‘s “theory of the case” for removal. Id.; see Agyin, 986 F.3d at 175. To the extent the parties raise factual disputes about the scope of a defendant‘s federal obligations, Congress gave federal officers “the protection of a federal forum” in which to resolve those disputes. Willingham, 395 U.S. at 407. As we explain in more detail below, Caremark premised removal on its theory that its PBM services for FEHBA were indivisible from its PBM services for private entities. In this way, Caremark alleged that it performed the charged conduct on behalf of a federal officer. Concluding that Caremark‘s actions, Before addressing the effectiveness of the Commonwealth‘s disclaimer, we briefly consider Caremark‘s case for removal under § 1442(a)(1) absent the disclaimer. Cf. One & Ken Valley Hous. Grp. v. Me. State Hous. Auth., 716 F.3d 218, 224 (1st Cir. 2013) (noting our “obligation to inquire into our subject[-]matter jurisdiction sua sponte“). Recall that the Commonwealth blames Caremark‘s rebate negotiations for insulin prices’ upward rise over the years. The Commonwealth claims that these negotiations were part of a larger scheme between Caremark and manufacturers to inflate insulin prices. This charged conduct Caremark also possesses a colorable federal defense for its negotiations on behalf of FEHBA carriers. FEHBA contains an express preemption provision, which states that “[t]he terms of any [FEHBA] contract” relating to “benefits . . . preempt any The Commonwealth‘s position is that it disclaims “relief relating to any federal program,” including FEHBA, which it argues negates Caremark‘s ability to satisfy the “acting under” and “colorable federal defense” elements. Caremark, however, alleges that it negotiates for rebates jointly for its FEHBA-based and non-FEHBA carriers. And those negotiations lead to rebate agreements, which do not distinguish between FEHBA and non-FEHBA plans. Considering the level of OPM‘s involvement in what provisions these rebate agreements must contain, holding Caremark liable for its role in the scheme to inflate insulin prices necessarily includes holding Caremark liable for its Once we credit these allegations and theory of the case “for purposes of . . . our jurisdictional inquiry,” Acker, 527 U.S. at 432, the disclaimer was not effective to prevent removal. Rather, the disclaimer would permit the Commonwealth to recover “based on [Caremark‘s] official acts.” Batchelor, 185 F. Supp. 3d at 1363 (citations omitted). That is so for three interrelated reasons. First, by targeting Caremark‘s rebate negotiations while disclaiming any “relief relating to a federal program” or contract, the Commonwealth necessarily targets what Caremark alleges are “act[s] under” a federal officer‘s authority. See Moore, 25 F.4th at 34. After all, Caremark alleged that it negotiates for rebates with manufacturers simultaneously for FEHBA and non-FEHBA plans; there are no “FEHBA-only” negotiations. And Caremark alleged that when it negotiated for rebates during the period relevant to the instant dispute, its negotiations led to rebate agreements that covered both types of plans. So, if Caremark is liable for its conduct in negotiating rebates for private clients and FEHBA plans, then it could be liable for its conduct under OPM‘s direction -- no matter what the disclaimer says. See, e.g., CaremarkPCS Health LLC, 2024 WL 3770326, at *2 (Ikuta, J., concurring) (noting that “no disclaimer, however worded,” could prevent removal because Second, because these negotiations allegedly cannot be disassembled, crediting the disclaimer would foreclose Caremark‘s right to have a federal court evaluate its “colorable” preemption defense under FEHBA‘s express preemption provision. Third, crediting the disclaimer would undercut § 1442(a)(1)‘s requirement that federal courts determine whether a defendant acted under a federal officer‘s authority. The disclaimer forgoes relief “relating to any federal program,” but Caremark claims that it negotiates for FEHBA and non-FEHBA plans in one fell swoop. Given this purported indivisibility, the Commonwealth‘s recovery for how Caremark‘s rebate negotiations drove insulin prices upward means that the Commonwealth could recover in the Court of First Instance for Caremark‘s acts under a federal officer‘s authority. That would deprive Caremark of the federal forum to which it is entitled. Cf. Despres v. Ampco-Pittsburgh Corp., 577 F. Supp. 2d 604, 608 (D. Conn. 2008) (rejecting a disclaimer where the plaintiffs purported to exclude all federal claims but sought to recover for asbestos exposure related to the defendant‘s work for the Navy). We do not believe it possible to divide Caremark‘s federal and non-federal work to enforce the disclaimer for two reasons. First, we must “credit” Caremark‘s “theory of the case” for removal. Acker, 527 U.S. at 432. We have explained why that means that we shall consider its work indivisible at this early juncture. Second, under Caremark‘s removal theory as “cabined by the notice of removal,” Lopez-Munoz, 754 F.3d at 4, Caremark conducts one negotiation, and the Commonwealth would hold Caremark liable because this negotiation allegedly inflated insulin prices. Caremark claims to have performed its actions simultaneously for private clients and the federal government, invoking a colorable preemption defense. This defense‘s presence is “decisive upon the subject of jurisdiction.” Cooper, 73 U.S. at 252. Crediting the disclaimer thus would trample a “primary purpose[]” of To get around this impasse, the Commonwealth promises to “remove claims relating to . . . FEHBA” and disavow restitution, civil penalties, disgorgement, and injunctive relief relating to the same. This promise does not address the problem. The Commonwealth claims that how Caremark negotiated rebates inflated insulin prices. But this “charged conduct,” Moore, 25 F.4th at 34, is alleged to be indivisibly federal and non-federal. Even with the Commonwealth‘s promise to tailor its relief, its theory of liability premised on the negotiations make it possible that it will recover for work that Caremark claims to have “carried out” for the federal government. Id. The Commonwealth relies on location-based disclaimer cases to support remand. In its view, claims not related to a federal program are as “discrete and readily identifiable” as claims that do not arise on federal property. We are not persuaded. When a plaintiff disclaims claims arising from their injuries on federal property, the plaintiff‘s remaining claims presumably arise from their injuries on private property and are disconnected from the defendant‘s work for the federal government. See Dougherty, 2014 WL 3542243, at *1. A defendant cannot claim that it acted for a federal officer and is entitled to federal immunity in that scenario. See id. at *8-10; The disclaimer here does not assuage that concern. Based on the allegedly indivisible nature of Caremark‘s negotiations, the Commonwealth‘s “alleged injury could . . . have happened under the direction of a federal officer,” presenting a colorable federal defense. Lopez, 2024 WL 1907396, at *11. And we have explained why this means that a federal court would lose the opportunity to adjudicate that defense -- a result that the federal officer removal statute prohibits. Location-based disclaimer cases are dissimilar. The district court was also troubled by the consequences of Caremark‘s indivisibility argument. It believed that the argument‘s “logical end” would permit “any organization that contracts with the government” to remove “if any portion of [its] But recognizing the indivisibility problem here will not permit every private entity contracting with the federal government to remove. Government contractors may only remove when their relationship with the government “is an unusually close one involving detailed regulation, monitoring, or supervision.” Watson, 551 U.S. at 153. For example, a contractor is unlikely to meet the “acting under” requirement if it sells the government an off-the-shelf commercial product or its relationship with the government is a typical, arms-length business deal. See, e.g., City & Cnty. of Honolulu v. Sunoco LP, 39 F.4th 1101, 1108-09 (9th Cir. 2022) (concluding that private companies’ repayment of offshore leases and operation of strategic petroleum reserve was not performed under federal authority where companies acted independently and established only “a typical commercial relationship” with the government); Att‘y Gen. of N.J. v. Dow Chem. Co., No. 23-cv-02449, 2024 WL 1740087, at *5-9 (D.N.J. Apr. 23, 2024) (rejecting defendant‘s argument that it acted under federal authority by supplying government with chemicals because it sold substantially similar products to private parties). Nor may a defendant remove when confronted with a location-based disclaimer that limits the plaintiff‘s claims to those arising only on private But that is not so here. The Commonwealth‘s disclaimer failed to address Caremark‘s allegation that its service for the federal government is indivisible from its service for private clients. The federal officer removal statute was designed to afford a federal forum to those private actors who, as alleged here, help the federal government carry out its duties -- even if those actors perform the same service jointly for the federal government and private entities. The disclaimer did not acknowledge this potential indivisibility and cannot halt removal. In sum, we credit Caremark‘s theory of the case that its federal and non-federal work is indivisible based on the way it negotiates rebates for the federal government and private clients simultaneously, and advise district courts prospectively to so credit the removing parties’ theory of removal under § 1442(a)(1). Analyzing Caremark‘s argument for removal absent the disclaimer, we hold that it satisfies Section 1442(a)(1)‘s three-part test. Because of this alleged indivisibility, the disclaimer did not The district court remanded because it credited the Commonwealth‘s disclaimer. Although we do not reach the same conclusion, we “commend the district court for attempting to parse out [the] limited jurisprudence” on the disclaimer doctrine (while managing ably without any First Circuit precedent on the subject). Walsh v. Unitil Serv. Corp., 64 F.4th 1, 5 (1st Cir. 2023). This opinion shall hopefully clarify how district courts in our circuit should analyze similar disclaimers. For the reasons stated, we reverse and remand. The district court shall order the removed case returned from the Court of First Instance. Costs are awarded to Express Scripts and Caremark.iii. Removal Proceedings
A. Standard of Review
i. Statutory Background
ii. Three-Part Test
iii. Disclaimer Doctrine
C. Application
III. CONCLUSION
