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DOL Issues New FMLA Opinion Letters

"School employers specifically should ensure they have practices in place to monitor exactly when employees' use of FMLA leave coincides with school closings, regardless of whether those closings are planned or unplanned.... FMLA-covered employers should account for travel time associated with medical appointments when evaluating employees' requests for FMLA leave for their own serious health condition or a family member's serious health condition."

PBM's Definition of 'Retail Pharmacy' Could Mean 25 Percent Cap on Single Therapeutic Category

"Based on the specific language in this new provision, Optum appears to assure pharmacies that if credentialed as a specialty and/or compound pharmacy, the 25 percent cap on a single therapeutic category does not apply.... The key takeaway is that pharmacies must take a close look at and analyze their PBM agreements to determine whether they have a 'specific arrangement' (i.e., specialty or compound credentialing) that would render the 25 percent threshold policy inapplicable."

PBM Agrees to Second Settlement for Alleged False Claims Act Violations Over Insulin Refills

"Just a few weeks after CVS Pharmacy Inc. agreed to pay $18.2 million dollars to resolve alleged violations of the federal and California False Claims Acts ... CVS has once again agreed to pay almost $37.76 million dollars to settle another civil fraud case brought against it by the Department of Justice.... In the stipulation and order of settlement and dismissal, CVS admits, acknowledges and accepts responsibility for being overpaid by government healthcare programs, over dispensing and refilling prescriptions too soon."

PBMs Ask Eighth Circuit to Overturn District Court's Refusal to Halt FTC Proceeding

"[J]udges on an Eighth Circuit Court of Appeals Panel briefly questioned the pharmacy benefit managers (PBMs) accused by the [FTC] of artificially inflating insulin prices by rigging the pharmaceutical supply chain in their favor and preventing patients from accessing affordable life-saving drugs. These PBMs are attempting to stop the FTC's internal proceedings against them while the constitutional challenge plays out.... Essentially, the PBMs are arguing that they will be irreparably harmed if their claims are adjudicated in the FTC's internal administrative proceedings instead of federal court." [Express Scripts, Inc., v. FTC, No. 24-1549 (E.D. Mo. Feb. 18, 2025; on appeal to 8th Cir No. 25-1383; oral arg. Nov. 19, 2025)]

Medicare Telehealth Claims Reimbursement and Flexibilities Face Limits During the Government Shutdown

"[On] October 21, 2025, CMS ... [directed] MACs to lift the claims hold for Medicare physician fee schedule, ground ambulance transport and federally qualified health center claims, including telehealth claims that 'CMS can confirm are definitively for behavioral and mental health services.' ... CMS directed MACs to continue to temporarily hold claims for nonbehavioral and mental health services telehealth claims and for acute hospital care at home claims."

California Establishes Extensive Rules for Pharmacy Benefit Manager Conduct

"[K]ey provisions ... include: [1] an 'any willing provider' requirement; [2] a prohibition on spread pricing; [3] a requirement to use a passthrough business model; and [4] a general prohibition on retroactive payment reductions and payment reductions through a reconciliation process. Effective dates vary, with many of the provisions applying to any contracts from January 1, 2019, or later and other provisions applying to contracts beginning January 1, 2026, or 2027."

NYC Council Passes New Earned Safe and Sick Time Act Requirements for Employers

"The latest ESSTA amendments seek to mandate the front-loading of an additional 32 hours of unpaid safe and sick leave for employees upon hire and each calendar year thereafter ... [T]he bill seeks to expand the list of eligible safe and sick time uses for leave under the ESSTA.... The collapsing of the [NYC Temporary Schedule Change Act (TSCA)] into the ESSTA provides some consistency for employers who have struggled to synthesize these competing statutory schemes."

New Hampshire Employers Must Comply with New Unpaid Parental Leave Law in 2026

"Effective January 1, 2026, New Hampshire employers with at least 20 employees must provide unpaid leave rights for employees to attend medical appointments related to childbirth, postpartum care and infant pediatric care.... The law entitles covered employees up to 25 hours of unpaid leave from work to attend the employee's own medical appointments for childbirth or postpartum care, or the employee's child's pediatric medical appointments within the first year of the child's birth or adoption."

West Virginia Sues Pharmacy Benefit Manager for Manipulating Opioid Crisis

"[T]he state of West Virginia ... filed a federal court action against pharmacy benefit manager (PBM) Express Scripts Inc. (ESI) based on its alleged role in manipulating and exacerbating the opioid overdose epidemic. The West Virginia attorney general asserts that ESI, as a PBM, held a 'uniquely powerful position' within the 'prescription drug ecosystem.' " [West Virginia v. Evernorth Health, Inc., No. 25-0182 (N.D.W.V. complaint filed Aug. 15, 2025)]

Pharmacy Benefit Manager Ordered to Pay $290 Million for Medicare Overbilling

"This case arose from Caremark's failure to comply with a change in Medicare's policies intended to curtail opaque pricing practices.... This case and Judge Goldberg's judgment further demonstrate to PBMs the consequences of failing to keep up with changes in the law and the increased scrutiny PBMs are now facing from federal agencies." [U.S. ex rel Behnke v. CVS Caremark Corp, No. 14-0824 (E.D. Penn. Aug. 19, 2025)]

District Court Preliminarily Enjoins Arkansas' Ban on PBM Ownership of Pharmacies

"Although this order likely postpones Act 624’s effective date, a preliminary injunction is just that: preliminary. The court’s reasoning for the commerce clause and supremacy clause challenges rests entirely on a preliminary assessment of existing law. But since those challenges are now moving to litigation, both parties must now present evidence for their claims, along with additional legal arguments, which will inform the final decision on Act 624 at trial." [Express Scripts, Inc. v. Arkansas State Board of Pharmacy, No. 25-0520, 25-0524 (E.D. Ark. Jul. 28, 2025)]

New Paid Prenatal Leave Notice and Policy Update Obligations Have Arrived for All New York City Employers

"[S]ince January 1, 2025, the New York State Paid Sick Leave Law (PSLL) has required all private-sector employers, regardless of size, to provide paid prenatal leave banks to all full-time and part-time employees.... Effective July 2, 2025, as described in the ESSTA's updated FAQs, the ESSTA amendments require that New York City employers take affirmative steps to comply with the updated rules, which includes new pay stub requirements, updates to policies and the provision of a new notice."

PBM Hit with $95 Million False Claims Act Judgment

"This ruling is particularly significant as it sheds light on the all-too-opaque process of drug pricing.... When PBMs are accused of having violated the False Claims Act by overbilling Medicare -- when Caremark is supposed to be reporting the actual prices remitted in reimbursement to pharmacies for Medicare Part D drugs -- it follows that the reimbursement paid to pharmacies is significantly less than what it otherwise should be." [U.S. ex rel Behnke v. CVS Caremark Corp., No. 14-0824 (E.D. Penn. Jun. 25, 2025)]

Massachusetts Supreme Judicial Court: No 'Back Door' Coverage of Nonsolicitation Agreements Under Massachusetts Noncompetition Agreement Act

"The Supreme Judicial Court’s (SJC) decision reversed a lower court’s ruling that had disrupted the long-held understanding that the MNAA categorically excludes nonsolicitation agreements, and it further clarified the scope of the MNAA’s reach.... [T]he Miele case remains a cautionary tale for employers when seeking to reaffirm restrictive covenants, a common practice when an employee resigns." [Miele v. Foundation Medicine, Inc., SJC?13697 (Mass. S.J.C. June 13, 2025)]

PBMs Sue to Enjoin Arkansas Law Blocking Them from Operating In-State Pharmacies

"Caremark and ESI each seek injunctive relief to prevent the implementation and enforcement of Act 624, as well as a declaration that the law is unconstitutional and preempted by federal law.... Act 624 prohibits PBMs from obtaining or holding, directly or indirectly, a permit for the retail sale of drugs or medicines in the state of Arkansas, including permits for mail-order pharmacies. The law is set to become effective on January 1, 2026."  [Express Scripts, Inc. v. Arkansas State Board of Pharmacy, No. 25-0520 (E.D. Ark. complaint filed May 29, 2025); CVS Pharmacy, Inc. v. Arkansas State Board of Pharmacy, No. 25-0524 (E.D. Ark. complaint filed May 29, 2025)]

Michigan Attorney General Sues Two PBMs, Alleging Price-Fixing and Other Anticompetitive Conduct

"The 89-page complaint details the decline of independent pharmacies in Michigan and across the United States and alleges that ESI and Prime's arrangement ... harmed Michigan residents by decreasing healthcare access, increasing healthcare costs and decreasing the number of small businesses in Michigan. This is the latest in a series of lawsuits alleging collusion by the nation's major PBMs and continues a nationwide trend of increased scrutiny of PBM conduct." [Michigan v. Express Scripts, Inc., No. 25-11215 (E.D. Mich. complaint filed Apr. 28, 2025)]

Medicare Prescription Pricing Faces Uncertainty with Revocation of Executive Order 14087

"On January 20, 2025, President Donald Trump revoked Executive Order 14087 ... which had promoted analyzing new healthcare payment models that would lower prescription costs for Medicare and Medicaid beneficiaries.... The potential impact ... includes: [1] uncertain out-of-pocket copayment models and [2] uncertain drug pricing policies, including rebates and reimbursements received by pharmacies."

FTC Report Shows PBMs Profit from Specialty Generic Drug Markups and Reimbursements

"The [FTC report] found that PBMs earn several billion dollars annually from increasing the cost of specialty generic drugs by dispensing them through affiliated pharmacies. Of the specialty generic drugs the FTC analyzed, PBMs marked up nearly two-thirds of them by more than 100 percent [and] marked up the cost of over one in five ... by over 1,000 percent. The report also finds evidence that PBMs steer patients with highly profitable medications toward affiliated pharmacies more aggressively than for patients with less profitable medications."

Three Pharmacy Benefit Managers Will Face FTC in Joint Trial for Insulin Rebate Cases

"The case alleges that the three largest PBMs -- Caremark, Express Scripts and OptumRX -- used unfair rebate schemes to artificially inflate the price of insulin. In mid-October, the PBMs each moved for separate proceedings, arguing that a consolidated trial could create confusion. The judge held that the factual differences in each of the cases were 'minimal and manageable.' " [In the Matter of Caremark Rx, No. 221-0114 (FTC Nov. 14, 2024)]

Michigan Attorney General Sues Two PBMs, Alleging They Fueled Opioid Crisis

"[T]he complaint's primary allegations are that Optum and ESI both promoted opioid distribution for their own profit and failed to use the tools at their disposal to combat opioid overuse after the crisis became apparent. The complaint identifies utilization-management programs and drug formularies available to PBMs to monitor drug distribution."