Recently, the Sixth Circuit issued a significant ERISA preemption ruling for employers and pharmacy benefit managers (PBMs). The court held that Tennessee’s PBM laws, which require “any willing” pharmacy access and limiting incentives that steer members to plan‑favored pharmacies, are preempted as applied to self‑funded ERISA plans. The ruling draws a clear line between permissible PBM cost regulation and impermissible interference with plan design and administration.
Ninth Circuit Upholds Administrator’s Denial of Residential Mental Health Benefits Under ERISA
In an unpublished memorandum decision, the Ninth Circuit in R.R. v. California Physicians’ Service d/b/a Blue Shield of California, affirmed the insurer and administrator’s denial of benefits for a dependent’s residential mental health treatment under an ERISA‑governed plan. The court applied abuse‑of‑discretion review and concluded that the denial was supported by the plan’s medical‑necessity criteria and the administrative record. The dissent, however, argued that the majority failed to meaningfully account for a structural conflict of interest and for the administrator’s handling of treating‑provider evidence and prior failed lower levels of care.
Supreme Court Declines Review in Guardian Flight, Leaving Intact Fifth Circuit Ruling That No Private Right of Action Exists to Enforce IDR Awards
On January 12, the U.S. Supreme Court denied the petition for writ of certiorari in Guardian Flight, leaving in place the Fifth Circuit’s June 2025 decision that we covered in our prior post (available here). As a result, within the Fifth Circuit, providers cannot rely on the No Surprises Act (NSA) itself to enforce Independent Dispute Resolution (IDR) awards in court and face a heightened standing bar for ERISA-based claims where patients are insulated from financial harm. And the persuasive effect of the Fifth Circuit’s holding is bolstered nationwide.
Ninth Circuit Reaffirms Broad ERISA Preemption Regardless of Concurrent ERISA Claim
On November 24, the Ninth Circuit issued an unpublished memorandum disposition in Dedicato Treatment Center, Inc. v. Aetna Life Insurance Co., affirming dismissal of an out-of-network provider’s state-law claims as preempted by ERISA’s remedial scheme. The panel’s brief decision underscores that the Court’s 2024 decision in Bristol Holdings (discussed here) applies broadly to state-law causes of action arising from pre-service verification-of-benefits and authorization communications, even where a provider also pleads an alternative ERISA benefits claim pursuant to an assignment of benefits from the member. Although not precedential under Ninth Circuit Rule 36-3, the disposition is a clear, persuasive affirmation of Bristol’s reach.