pharmacy benefit managers or drug middlemen that reimburse pharmacists for the cost of prescription drugs those reimbursements are frequently below a pharmacist cost that drives pharmacist out of business and has left many communities without a pharmacist agnon one hundred responded to that practice by regulating but p p m xp a pharmacist that response isn't preempted for three reasons it doesn't regulate benefits it doesn't regulate i ended ministration and it doesn't regulate discriminate against the risk and cities st act nine hundred dollars does not regulate benefits instead it regulates the price of drugs that a plan has already decided to cover that's right regulation and under travelers that's not preemptive and that's because cost differences don't force plans to behave differently in different states and thus don't interfere with uniform administration nd or if it doesn't preempt walls that employment or enforce rate regulation indeed absent enforcement there is no regulation and responded doesn't dispute that i had nine hundred and four spent mechanisms implement our controls rate regulation or for that matter to those mechanisms regulate planet ministration rather they regulate m reimbursement practices and plans don't control those practices and stead those practices are governed by p p m pharmacy contracts that aren't even shared with plants and it therefore defies common sense to suggest that ag nine hundred regulates planet ministration there is no connection with problem rd agnon one hundred does not refer to a risk under dillingham only laws to treat arisa plans differently contain a prohibited reference and are preempted respond doesn't even attempt to argue that's true here nor could it in fact nine hundred dollars applies to p p m support for both a risk and non arista entities this court should reverse the judgment councils your basic it seems to me is that the law regulates drug prices that's certainly the purpose of it but it doesn't say anything about drug prices instead it talks about what plans have to pay for benefits the methodology of determining the amount to be paid the timing and procedures for updating payment schedules the dispute resolution process sees remedies it has things like the authorizing declining to dispense i mean at the end of the day all this might have an impact on drug prices but it seems to me that it's very different and those differences really do go to what a risk is trying to regulate your honor i i think at the end of the day the one thing that affects plans and in fact the only way in which that our law actually affects plans is it might alter what plans ultimately pay our law does not apply directly to plans or laws directed at p m and what p b s pay pharmacy's so in that sense the only effect on a plan are the only effect that a plan might see might be the possibility that at the end of the day it might pay a little bit more but that's the same thing was true in travelers and travelers when new york regulated what commercial insurers were paying hospitals with the surcharges this court acknowledged that that the odds were that those surcharges would be passed on to the plans and that might affect how the the benefits packages that plans might choose to all offer it might influence or choice of administrator but what the court emphasized is at the end of the day that's just cost and it might influence shopping decisions but ultimately what's important is it's not dictating substantive plan decision making and the same thing is true here we haven't dictated how plans resolved anything we haven't dictated plan decision making about what to provide or how to provide it or anything like that all of the mechanisms that your honor referred to really are mechanisms that are p b m mechanisms the plans don't have any insight into any of that stuff and and again from a plant's perspective the only impact would be on prices just like isn't it was true in travelers who counseled justice thomas following up on the chief justices question it seems that if the the pharmacy wins its appeal that it has to rebuild and it seems that there's then it determines when the co pay is a determination is made final so that seems to be something the co pay determination that you would normally expect the plan to  decide so isn't that something central to the plan so your honor it it actually doesn't affect things like co pay and in fact co pay would be a flat fee for instance that the  beneficiary would pay and the only adjustment that's made as a result of a reimbursement appeal which by the way happens now the only adjustment that's made as a result of that would be the adjustment of what the p b m owes the pharmacy i don't disagree your honor tha small number of cases there might be some downstream impact on what the beneficiary of those in a co pay situation that is which is eighty one percent of situations and that's not true because the co pay is a flat fee and that's never going to change but in those cases where we're talking about of coverage which is the co insurance weight or you will get your drug minus this co payment none of none of that changes agnon one hundred doesn't impact any of that and that really underscores that that we haven't regulated central plant administration the same thing would be true frankly today drug prices float up and down they represent that they are continuously adjusting the mac list every day to reflect market prices so that means that today a beneficiary who is under let's say a co insurance plant might pay one dollar price for a drug at the counter and might be something else the next day just because the prices change it but it doesn't mean that that the benefit has changed because the benefit is is not the magnetized the benefit is what the plan of the plan to pose to the law like nine hundred or simply more simply passes a law that says all insurance plans must play druggists at least x or no or no insurance plan can pay more and state c is arkansas right i don't know what the percentages are but you can tell me does that matter if it doesn't your honor because what arkansas of all actually regulates here is the price  plate pays the pharmacy and because what we're not talking about here is it's not a matter of central planted ministration as this court explained in travelers the amount that a service provider is paid it really doesn't matter at the end of the day whether the  that in other words it doesn't matter what the scenario is ok well imagine what the law says in states where every insurance plan is in a of plan in this state must pay a druggist's for aspirin no more no less than three dollars twenty cents did i guess it would depend on the scenario but if if if if it were exclusively an application teresa planned as a result of there the only ones who fit the definition then your honor we would potentially have a reference to problem but again that that's not the issue here because our law doesn't apply exclusively to risk a plan just what i think so i'm not that the record doesn't reflect what the percentage is that's fact ultimately binary supplant but i we do know that it's not all of  arkansas and obviously a p p m that works for a commercial insure that was purchased under the change would also be covered by our law thank you counseled by justice alito what we have to do in this case is to interpret and apply a federal statute and what that statute says is that it preempts quote any and all state laws in so far as they may relate to any employee benefit plan covered by today when we interpret statutes what we generally do is to ask what they would have been understood what the language would have been understood to mean at the time given that ben and we have moved away from interpreting statutes in light of the purposes that they are thought to serve so if we were to take that approach here wouldn't that lead to the conclusion that  that this law is preempted no your honor because when congress used the phrase relate to it could not possibly have meant anything and everything that possibly relates in some sense to in orissa plant i think is just scalia famously explained joined by justice ginsburg that is every curbstone philosopher knows everything is ultimately related to something to everything else and that that really means there would be no room limiting principle and that would present serious constitutional concerns so i think given that what this court has historically done when it's had language like that is broad is that that would present problems or as broad as it is here it looks to the overall structure of the statute for the overall purposes of a recess what is a risk that concerned with what is it specifically our the way we generally interpret statues in this case you would be in a lot of trouble wouldn't you i don't think so your honor because i think ultimately at the end of the day that you have to interpret that that language in light of the remainder of actually is concerned with which is the planned beneficiary relationship and and the things that are specifically listed in the recess that are designed to ensure benefits are more secure and act nine hundred in no way regulates the planned beneficial relationship and thank you counsel counsel i want to follow up a little bit justice briar's question what i am interested in is a different scenario than this law but if we if we rule in your favor i'm not sure what the distinguishing factor might be between this law as between you're a lot of the hypothetical i'm going to post let's say a state decides we're going to have three tiers of  c drugs a one thousand dollars and let's say a plan or let's say just about every plan to five that the price of tea or c drugs was so high that the plan simply could not afford to provide those drugs to its participants that is affecting the beneficiaries and what they get and it's affecting at least for those who  not on fixed co pays but on percentage co pays your fixed ones i'm assuming is when you pay fifty one thousand and fifteen or twenty dollars for each drug as opposed to one that says well paying eighty percent and you pay twenty dollars beneficiaries are being directly affected and plans are being affected quite directly because they're being blocked out of any market whatsoever for a cheaper drug why wouldn't that nd scenario be preempted as a broad principle the same rule generally would apply which is that the cost merely influence a decision and that's not sufficient for preemption but what i would add is the honor if the scenario i think your honor is posing would be addressable under what travelers said that if you had a great regulation that it was in fact so onerous that it dictated substantive plan decision making sort of the scenario drawn or suppose where it's a falcon dollars for a drug if it's true that that's in fact so onerous that it's dictating the terms of the substantive decision making of the plan was a beneficiary what's covered it's that kind of of  l that could be preempted under travelers travelers left open that possibility to ensure things like that didn't happen but that's not this case this case all the asli they haven't made an argument that there are drug regulations so onerous that it would take their subset of decision making and regulating plans so if the plan managed prescription drug benefits itself the s c says that would be a different question and we shouldn't reach that question i had thought that your argument really made that distinction irrelevant but when you spoke when you answered the chief question you said well our laws directed to p b s not plans so i guess what i want to ask you is were we to rule in your favor should we write an opinion that really makes that critical or should we write an opinion that makes said essentially irrelevant i think the easier approach your  honor the way i answered i think the easier approach would would essentially be that this case is basically travelers because in travelers it was the commercial insurers that were being charged the surcharges and the way the court analyzed it was to say that the only potential impact on the plans was it might potentially be passed along to the plans and that might influence decisions that same framework applies here because we're the great regulation applies to the p p m pain pharmacy and it's possible that the plans not required but it's possible the plans might choose to do or the p b s might choose to pass that on to the plans so i think the court could resolve this case entirely on that basis my my point however was that at the end of the day i guess it really reporting requirements for all kinds of health care plans and quoting a recent plans and that it just incidentally affected a recent plans of course we held that that preempted there and councils got to get up and tell that this is exactly like that case or very close to it because it affects drug prices all health care plans have to pay if you care to respond to that now sure your honor i this case is is very different from back and i think the critical difference is that go bay ultimately was about a statute the regulated a fundamental arista function i think the language this court used was that it was a direct regulation of the fundamental arista function which is record keeping and reporting that specifically listed in detail to refer and the department of labor has additional power to addition to issue additional regulations under and because it was a specific arista function that generally left to the states to regulate and in fact the p b m pharmacy contract for instance those are ordinary state law contracts that are ordinarily subject to state law enforcement mechanisms if there was a tank you don't know that consul justice  clear negative effect on planned beneficiaries who are arkansas workers and if so it must relate to orissa plans do you agree or disagree with the premise that this will have an effect on plan that's being regulated there really is is the margin we are requiring i guess you could say p p m to reallocate some of that margin back to to the local pharmacies in order to ensure that they can remain in business and so that small town independent rural pharmacies across our state people in those communities retain access to pharmacies because when a small town pharmacy closes it in hampton or gillette arkansas it might be forty miles to get a drug that might be thirty miles to get an immunization so we're  protecting those individuals in those communities but i also think that the decision by the p p m there's there's no requirement that the p b m pass on any cost increases that might come along with that to the plan that's entirely up to the p m s business decision it can decide not to pass those along and if they're representations blow if they compete competitively based on price is true then it may be true that some p p m choose to pass on those costs some do not but ultimately that's up to the p p m's that's not a product of anything that arkansas has done and it might influence plan decision making but i can't guarantee that that's going to be the case any more than that was the case and travelers thank you counsel wanted to take a minute to wrap up thank you mr chief justice at the end of the day or if it doesn't preempt state regulation and act nine hundred is state regulation indeed to put an even finer point on it this case is travelers all the provisions at issue here regulate rates or at a minimum they all implement or enforce our consults rate regulation and respond it doesn't dispute that and to the extent that respond it relies on the complexity of the p p m pharmacy greenberg process that also doesn't change the reimbursement appeals to set prices and all that arkansas has dawned on is impose a great regulatory rule of decision on top of the system that the p b s themselves designed and for the same reason that new york's rate regulatory rule of decision wasn't in travelers regulates the relationship between p b s and pharmacies namely the p b s method of reimbursing pharmacies for prescription drugs so the question becomes is pharmacy reimbursement a central matter of administration the answer is no that regulated the method for reimbursing hospitals state law here which regulates the method for reimbursing pharmacies have to just english or of appeals judgment should therefore be reversed counsel i want to focus i think it's on the same question that justice kagan asked your your friend much of your brief focuses on the fact that regulation here is directed to a rd party rather than a plan and then at the very end i think you say well it doesn't really make that much of a difference so is your approach focusing on who is being regulated or what is being regulated it is focused on what is being regulated as i said at the outset our test is does the law in travelers on insurers and not plans and sounds whereas the law here does not response to that argument was twofold st to say that that's just a misreading of the state law here it doesn't apply directly to plants and more importantly secondly that even if it did it wouldn't matter because at the end of the day pharmacy reimbursement just isn't a central matter of kind of ministration thank you counsel justice thomas chief i have no questions he addressed my and asked whether a state law fell within the in the field that a recent preempts do you recommend that we take that approach would it work and i think the key language here is actually not related to you look at the text that says the provisions of this subchapter and step chapter three shall supersede any and all state laws and so far as they may now or here have to relate to any field would be defined by the text of the preemption clause so the provisions of this subchapter and said chapter three that's the feel of the text marks out and i think tellingly there's really no way to respond i can prevail under that text because there provision in this subchapter or separate after three that speaks to pharmacy reimbursement rate this is a huge contrast with the globe a case where there's an entire part of the arista statute that addresses the reporting and disclosure of plain information so if the court were to take a tax base of more tax based approach i think that's an even steeper hill or respondent to climb well what you've just mentioned sounds more like conflict preemption to me than field preemption or do i misunderstand what you alito pointed to justice scalia and ginsberg views but there were others expressed by many of my colleagues and that's number of them make i point out that despite the differences the outcomes would still remain the same so is there a reason why we should go down one path now as opposed to another i don't think there's a strong reason to do so here a justice that i are because we think that is a pretty straightforward case even under existing precedent if you look at all the cases this court has found a state law to have an impermissible connection with the rest of their eight of them seven involved state laws regulating the planned participant or beneficial relationship regulating what health care services are covered who very benefits are calculated and how participants kind of force their own rights under the plan and there was an eight case kobe which involved a function that a risk that addressed this case falls within neither of those categories it's not a case involving a state law regulating the planned protest going to beneficiary lation ship and it's not a state law that regulates the function that a recess specifically addresses even have this core work to leave its existing precedent in place we think this is a pretty one of the main drivers of a recess preemption provision was a concern about uniformity and here we have forty five different states that have passed all kinds of laws with respect to the i'm wondering why that doesn't raise exactly the specter that the drafters of a recession we're concerned about where the p b m see you know we're trying to do forty five different things in forty five different states and a has to be is the lack of uniformity in an area that i respect cares about and i think this just goes back to the question i set forth the outs that if it's the law to regulate the central matter of planned administration then that's an area that arista cares about  and this uniformity in that area is going to be a good reason for a risk of preemption but if we're talking about an area of traditional state regulation that is beyond any central matter of an administration i think those uniformly concerns enough all state laws would preempt it i just do want to add that this is a you know when we talk about e b m pharmacy reimbursements it's not like this is an area that was marked by pristine uniformity you know whether there's proof preemption here or not thank you mr chief justice and good morning mr lew you said at the outset that cost is not a central matter of planet ministration and i think when you zoom out that statement suggests something's gone awry  here in the jurisprudence fix because costs will directly affect the benefits paid to beneficiaries and the goal of the rest after all was to protect american workers including it would seem against state regulation that would perhaps favor state businesses over state workers so why shouldn't a risk care about costs that are going to be increased and they're passed on in the form of lower benefits or worse benefits to two year arkansas workers slicing travelers already answers this question we had the same issue in travelers as the court recognized and page sixty nine t surcharges there are going to be passed along to plans and there'd been an official his invention really and i think the reason why travelers didn't think that was enough to trigger rissa preemption was because increased costs actually don't effect the basic bargain between the plans on the one hand and the participants in the beneficiaries on the other i totally agree that a risk was enacted to protect that relationship but increase costs don't affect the terms of that relationship you take the example of the co insurance yes it's true that if costs go up the dollar and cents amount you have to pay and call insurance would go up too but that was also true in travelers i mean the very st line of travelers said the surcharges were  on the patients themselves so the idea that the there might be some ca sharing arrangement between the patients there and the insurers was was right before the court and it didn't make a difference i think you have to ask in all these cases what is being regulated and if it's not the plan for to supply relationship itself which i agree is central to what arista cares about and there is no preemption thank you mr lew you have some time left want to take up to three minutes thank you so i just want to address some of the some of the questions that came out by i think you know mr chief justice you asked about about whether this is different from a rate regulation and i think it's important to emphasize that all of the provisions here do form a package they're all in aid of the same goal which is regulating rates i mean just just think about the regime in travelers the regime in travelers  are onerous and the regime here because they're this eight in a pretty heavy handed way was dictating exactly what the hospitals had to be reimbursed that was the argy rate plus a certain surcharge w arkansas has done here is actually more market based and more flexible instead of saying every time prescription x is is filled you must pay x amount of dollars a thing what the reimbursement amount is  can vary from pharmacy to pharmacy depending on the pharmacies at acquisition cost and the way to make that market based approach work is to create a mechanism where they plan where the p b m is and the pharmacies can work out the reimbursement rate that is a less restrictive probe and the regime that was before this before in travelers and i think it would be strange if a less restrictive approach was to have a greater connection with the risk of plans and also at that travelers rejected any distinction between a purely economic rate regulation and regulations that man affect procedures rattrap as a self discussed quality standards and workplace regulations su effect on p b s procedures but the court went out of its way to say look we can't draw any principled line between rate regulation on the one hand and all sorts of other laws on the other that have an effect on cost  i guess i'd just like to end by emphasizing that travelers really does decide this case by making clear that how a provider is reimbursed is not a central matter of finding ministration responded attempts to distinguish travelers please the court act nine hundred directly compels you receive planned administrators to comply with state specific rules and procedures in administering their benefits programs in doing so it adds to a  varying state laws that make uniform planted ministration impossible now arkansas says it can dictate how plans should be administered as a means of so called rate regulation but state regulation of  as a means to some other end whether it's rate regulation or otherwise has never been permitted none of the cases arkansas or the s g cites involve laws directing planted ministre toure's to do anything extending those holdings to a law like this which directly regulates planted ministration would breach a critical line travelers neither dictates nor even suggest otherwise the law of the regulated a health care provider by requiring it to impose a surcharge on patient as this court explained and has reiterated in hack verb in dillingham the new york law quote did not bind plan administrators to any particular choice and thus function as a regulation of the original plan itself nor did the indirect influence of the surcharge preclude uniform bid ministration or provision of a uniform interstate benefit package close quote act nine hundred dollars does bind plan administrator is to particular choices and in the welter of varying state laws makes uniform national plan to administration impossible preemption applies whether the plan administers the benefits itself or as most are required to do engages a p b m to do so on its behalf this court has never distinguished between planned administration and rd party administration that distinction made no difference and go back and it would have treated destructive effects on the  corrected the the main effect of the state law here is on what pharmacists get for for selling drugs and it's also the clear purpose of the law why don't we should we look at that underlying reality rather than the mechanics that the state imposes to achieve it mr chief justice i think the answer is no and i think the question that you asked my friend  general brawny provides the answer you can look and it would be one thing if arkansas said that pharmacies you know you know may or must receive x number of dollars for y drugs if that apply if that were what the law said and this is in many many ways not whether or not it would be preempted would require this court to decide the two questions that it reserved in travelers itself the st which is the last sentence of footnote four explained that the court did not address the surcharge statute in so far as it applied to self insured plans and the nd as my friend mentioned is that if the state law produced economic effect as to force the original plan to adopt a certain scheme of coverage it would indeed be preempted when you're either on or not the state state or the pharmacies fault that the p b m have such byzantine procedures that affect drug prices nobody is saying that it's anybody's fault the fact of the matter is that if you look through  dollars you will look in vain to find a single substantive provision that just says pharmacies can charge for this amount what the act does is essentially for thing it requires regular updates to mac list on a on a on a formula that is almost impossible to comply with but in the context of forty other states which have different schedules different rehearsal you've got one out of four and could you very briefly just say what the other three are yes the varying appellate varying different appeals procedures with different rules of decision a widely varying set of remedies that plan administrators have to provide and of course the various states with different decline to dispense provisions which directly deprive beneficiaries of a promised benefit and it's all of those procedures that go to what is indeed a central matter of planet ministration and certainly makes it impossible to have a nationally uniform planted ministration and consul i'm sorry i was looking at the wrong time allocation we have a little more time m really do two things that the st is set the cost of pharmacies and the state says that's not regulated and what the nd is to determine coverage i mean that's not preemptive but the nd is to determine coverage which they say is anything wrong with looking at it that way well i think it oversimplifies it to the point of distortion what this is directed at at plans and plan administrator is that use mac lists as part of their methodology for determining what benefits will be provided to which employees for which drugs in which pharmacies and it's the interference with the application of that methodology upon which the entire plan is designed that makes this so you know so preempted if i may just refer the court to the court's opinion and this is this is agel hoff quoting for halifax quote state regulations affecting and him and in a receptive land system for providing processing claims and paying benefits impose precisely the burden that a recent preemption was intended to avoid thank you  employs drivers all over the country it has a pretty good explication of how impossible uniform planned administration would be but just to reiterate and expand a little bit on the four points that identify the chief justice so arkansas requires regular updates to a mac list according to a sort of byzantine schedule there are forty other states that one choir of states but on different schedules with different triggers for updates and different substantive requirements for the update so plans have to have different state by state math lists there are thirty seven states including arkansas that require appeal procedures but they are all different eight states specify the particular rule of decision as arkansas does but they imply different standards and with different effects and so multi state land standards and procedures for appeals will vary state by state rd the remedies following the appeal procedure vary widely some states require revisions to the backlist some states require notice to other pharmacies some states like arkansas allow the pharmacy to reverse and rebuild but rebuilt but other states allow all pharmacies that paid that max price to reverse and rebuild there are four dollars states including arkansas that have declined to dispense provisions but they have different conditions for declining and so employees of the same company will have on equal benefits from state to state thank you but what kind of relate to and obviously the court struggled with that what about state setting prices high prices are low prices of hospital services it's interesting now you put that on and so you take an aspect of that you said well no it's the procedures that do use in order to decide what the prices are that's the problem but every form of regulation involves procedures they all do and therefore we're going to get into the same business how much procedure is too much i'm just too little what kind of procedures wouldn't it be simpler to read that word relate to that we'd have to go back on language and say what it means is ordinary principles of preemption they are complicated enough and they mean my goodness that a special group of words over in their reception just makes it life much more complex it concerns and as to the latter which is what we've been talking about this court has said it will be preempted if it does either of two things either the state law governs a central matter of planet ministration or it interferes with nationally uniform planted ministration now again out with just one more sentence to answer your question the difference isn't how many procedures it dictates or doesn't the difference as i pointed out when in quoting both travellers and dillingham is whether or not the law is directed at plan administrator or directed at  rd parties and in in the in this case if the test is whether or not it by quote binds plan administrators to any particular choice and  lands i don't think that there is an exemption from the sherman act or the clayton that i know you use forget that question because i don't have a time and i can't be clear enough go ahead good god i see your point justice alito and mr waxman you are stressing how complicated it would be for a t b m's to comply with laws like the arkansas law and similar laws in all the states but it struck me that what they do even without a law like arkansas is extremely complicated and it requires i'm sure the complicated computer programs and that's why apparently there are so few of these p b s that requires a pretty sophisticated entity to deal with the situation at all so in light of that why would it be so difficult and costly and burdensome for the p b m just deal with a variety of different state laws well you're quite right justice alito that you know as the d c circuit pointed out in its p c m a decision which both parties all parties are citing that this complexity of providing american workers with pharmacy benefits is tremendous and that's why as a practical matter they have to use rd party administrators to do this the fact that they have rd party administrators which allows them to provide these kind of benefits on a price efficient basis doesn't mean that that risk permits every individual state to add additional levels of complexity and if you just look at just the  dollars different tests and schedules for updating mac lists and what price consequences to plans and beneficiaries every update to the mac list has it's it's an immen complication and it affects the benefits that beneficiaries receive similarly the remedies that vary from one state or other him a pimp posing on plans that very often are natural national plans meaning that employees of the same company will have on equal benefits from one state to another and plans will have to have either plans themselves or using the rd party administrators that they have appointed as agents to administer the plan on their behalf different procedures and different remedies and different update schedules and every different state which themselves frequently change and many many of these requirements will turn out will require the plans to either change their summary plan of benefits their explanation of benefits when it turns out that the beneficiary  pay more in mississippi because of some requirement that applies after an appeal procedure or to tell people for example look you're a driver for j b hunt but if you try to fill your prescription in arkansas even though we have promised you that you can fill that prescription at this pharmacy with this co insurance or co pay obligation you have to understand that that pharmacy has the right to refuse to give you that benefit and you said that this that these laws affect the benefits that employees get but do we know whether that is in fact true do we know assuming they increase the costs for the p following st of all as i think both of my friends on the other side acknowledged you know one way or the other in the very short term or the long term this is going to cost plans more to administer and therefore is going to the the munificence of the benefits the pharmacy benefits the plans you'll be taken to work nd of all in terms of the decline to dispense provision that is an immediate and obvious error radiation of the beneficiaries promised right under the plan and i think  counsel following up a little bit on justice alito those question and turning it a bit on the ted the yes she had made an awful lot of his brief about the fact that this unfortunate mechanism fell on the p b m zf rather than the plan but as was pointed out and go bill we came to a different conclusion on the reporting requirement but what a ruling in this case in favor of petitioners have plants reconsider whether they're going to use p p m settle well i think they reconsider it if they thought and this was just too onerous  i think as a practical matter yes they definitely would reconsider and the and i think that points out the reason why in go back the court found completely of no moment whatsoever that the vermont state law  bait didn't even apply to the plan or the plan sponsor if it wasn't for the fact that they used a rd party administrator a law would have no application to them and the reason for that is that i mean just look what would happen if all of these state laws applying all these procedures and rules substantive rules applied to dash an ill planned r s a wouldn't counsel but i'm sorry to interrupt you but we do have limited time what i want to do is let's simplify the law anyone who pays pharmacies whether it's p b s or the plants themselves but anyone has to do the pricing in this way and they don't differentiate between plants they don't differentiate between being a p p m or not or anonymous a plan or not they just say pharmacies have to be paid at cost plus or whatever at minimum ok what how with their arguments change and how would your argument change so i think if if the law simply said pharmacies can charge x price for y drugs exactly that that would be the situation in travelers but on like the situation in travelers which addressed a charge placed on patient which then had implications for insurance companies not arista plans it would that that type of law would implicate the questions reserved in no four and roman numeral three of travelers but this law as as i think we've talked about doesn't doesn't do that it doesn't direct it isn't directed at pharmacies it's directed at plant administrators and it doesn't just apply a price standard it prohibits the use of a methodology that the plans have adopted in order to figure out what benefits they can provide at which pharmacies for which drugs and it lays on a you know multiple procedures that they have to follow and those both your friends on the other side place a great deal of emphasis on the distinction between claims process and and on the other hand the reimbursement process and they say basically if you look at our cases in particular travelers we have made that distinction time and time again that the reimbursement process is a process that involves the relationship between the plan and the provider and  action doesn't care about that the only thing a recipient ssion cares about is the relationship between the plan and the beneficiary such as in the claims process and here so why isn't that the way to look at th though i think you know this court has said has acknowledged in many cases and i gave you the quote from meghan hoffman for halifax that how plans manage calculate and pay for benefits and how sponsors design plans is the central matter of iraq a planned administration and it is important it is critical that this court maintain the line that it is always maintained between the potential preemption of a law that is directed at rd party providers of health benefits as was the case in travelers on the one hand and as this coin court pointed out underscored in travelers in dillingham a law that quote binds administrator is to particular choices and this functions as a regulation of the plan itself i'm sorry that i did i answer your question other sorts of general regulations about other kinds of benefits this follows up on justice kagan's line of questioning some some plans of course provide daycare benefits death benefits all all sorts of other kinds of of the answer that i just gave justice kagan a state law that says ok you know you know health care you know child care providers nursery schools and think daycare providers have to follow the all the following safety procedures which makes it more expensive they have to charge plans more that's traveling that is a state obligation or a state regulation imposed on somebody who is providing health care or life care products or services and the fact that you know some hospitals charge more than other hospitals has been thought at least in the traveller's context subject to the t reserve questions and travelers not to implicate preemption when the state law says to the plan in the plan administrator is you know if you have if you're providing death benefits you have to use the following procedures and you have to update these lists and you have to allocate benefits between the plan and the plan beneficiary and you have to let the plan beneficiary know that some funeral homes may refuse the services that we have assured you they will provide under the contract terms that would be preempted ok along similar but different lines what do we do with the fact that there are plenty of resupply and that operate without pharmacy benefit managers there are plenty of pharmacy benefit managers that provide services to not on a risk plans and of course your clients here are as i understand it all pharmacy benefit managers and no resupply and sweet we don't have an hour and a resupply and that's actually complaining about this before us so i understand it yes that's right i mean there are there and because briefs filed by sponsors of the recent plans but the plaintiffs in this case and therefore the respondent here is the pharmacy benefit manager association st of all i would say that it is it is not it is it's important to underscore as everybody recognizes that well over ninety five percent of employ  in fact required in order to provide this otherwise expensive benefit to use rd party administrators and a rule that distinguish between the application depending on whether you use this rd party administrator would have very grievous effect on the plans of plans willingness to provide this benefit which of course is directed at the single most sensitive aspect of the health care services and so i i don't know if i've hansard your question i may have talked myself through remembering what the question was but if i haven't these could be another chance thank you counsel justice cavanaugh thank you chief justice and welcome mr waxman thank you the the basic music or theme from the other side as i understand it is that a risk of focuses on the relationship between plans and beneficiaries and is not as concerned about the economic relationship between plans and pharmacies or health care providers even though as justice pryor rightly said state laws affecting that are related relationship would undoubtably effect it misunderstands the direct regulatory effect that the arkansas law has on the plan the design of the plan and how plans go about managing calculating and paying for benefits and that's that's the problem here it's it's the direct it's the fact that the law is directed at planned administration and in fact directed at in this regard as you know again to quote this court the planned system for processing claims and paying benefits i mean me the at nine hundred obviously the other side has put heavy emphasis on travelers and you would say travelers does not apply here and does not control here because most just leave you to fill in the blank there so you know travelers does not apply here because by its terms travelers traveler travelers was predicated on the correct conclusion that the new york surcharge law which required hospitals to impose certain charges on patients quote did not bind plan administrator to any particular choice and thus function as a regulation of the original plan itself nor did the indirect influence of the surcharge be uniform administrative practice or the provision of a uniform interstate benefit package and those to those two aspects of the plan in travelers and this court's decision in travelers and dillingham provides a very distinction that ought to be underscored here i respectfully suggest thank you mr waxman thank you counsel we have several minutes left if any of the justices have further questions ok if not mr waxman wanted to take up to three minutes thank you mr chief justice i don't i think i've pretty much covered what i what i wanted to say i think that  after nine hundred dollars makes uniform plan administration impossible and because it directly but online administer plan administrator is to particular choices and thus functions as a regulation of the arista plan itself it lies in the heartland of what section five hundred and fourteen a sought to protect and for that reason the judgment should be  if i could mr waxman you've used that terminology quite a bit finding administrators typically would have choices and i guess i would just like to understand particularly what you mean by that which choices that  in the mad max list upon which the plan's benefits and scope have been predicated it binds them to a particular schedule of updating mask lists that is that varies widely across the country it binds them to a particular appellate process with a particular rule of decision that varies widely across the country it finds them to apply particular remedies in the event that the appellate process that aspies the rule of decision and it binds them to inform their beneficiaries that notwithstanding the promise that the beneficiary can go to pharmacy x and receive drug was i with the following co insurance terms in fact the pharmacy now has the right under state law to deprive the beneficiary of that pro  which is about really where the focus of our argument is and and it's the same as the government's really our point is that that act on one hundred doesn't regulate central planet ministration and to take up on on mr waxman's last answer when when the court talks about central planted ministration and binding plants to things really what it's talking about is it's blinding plans to decisions about who's a beneficiary what's the benefit what's the degree of coverage that's the co pay co insurance rate cetera and how those things are determined it's not rate it's not what a rd party administrator pays for a service provider and the fact that that's what we're talking about here really makes this case exactly like travelers and makes us an easier case because travelers already address that issue in terms of attempting to distinguish travelers what i understand mister waxman to be sane is well it's somehow different because somebody different is being regulated or the surcharges are being or the the right regulations being applied somewhere else but in reality involved in travelers the surcharges were paid based on the commercial insurer that was being used if you're using a non blew you pay the surcharges here it's the same principle if you're using a p p m the p p m uses a mac list you play these right so they're really not distinguishable on the uniformity point really i don't see a lot of there there is a lot more uniformity than just uniformity here but at the end of the day what's most relevant is that it's not just uniformity with respect to corps planet ministration and mr waxman didn't point to any just uniformity with respect for planet ministration and this court has never said that this uniformity in the abstract is a problem because obviously that can't be true because the risk was an intended to create an entirely isolated  insulated universe immune from ordinary state market regulation another point that came up with the decline to dispense provision frankly that's inherent in rate regulation as we explained in the brief but it also operates like any number of other ordinary state regulations that even p c and made as a claim are preempted like for instance in arkansas a pharmacist has a moral objection to driving a particular medication but he declined to dispense that medication and even p c m made a claim that those laws would be preempted even though it would have the same effect and lastly to the end on a question the justice course it's asked which is about the limiting principle i think that's really the problem with p c m a's argument there is no limiting principle if you accept their position that cost any time a regulation imposes costs that can lead to preemption because it might affect the benefits calculation that really has no limiting principle it would frankly preempt things like state minimum wage laws that have exactly that same effect we would ask if this court reversed the judgment law thank you counsel the case is submitted