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RUTLEDGE v. PHARMACEUTICAL CARE 
MANAGEMENT ASSN. 
Opinion of the Court 

  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  cer-
tain 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 pharma-
cies 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, ap-
plies 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 (quot-
ing Dillingham, 519 U. S., at 325; ellipsis omitted). 
  Act  900  does  not  act  immediately  and  exclusively  upon