Related: Employers take fights with Big Pharma and PBMs over insulin price-gouging charges to one federal court

Up till now, the self-insured health plans in the MDL wave have been plans sponsored by government employers that are not subject to the Employee Retirement Income Security Act.

Braman will be the first private-sector employer and the first ERISA plan sponsor to join the MDL wave as a plaintiff, lawyers for the MDL plaintiffs say.

What it means: Because Braman will have the first ERISA plan in the MDL wave, it could have a big effect on what the court knows about how insulin pricing affects private-sector employers.

Braman could also affect what, if any, compensation ERISA plan sponsors or participants end up getting if the plaintiffs succeed at negotiating a settlement agreement that involves compensation or go to trial and end up prevailing in court.

Even if Braman and other self-insured plan sponsor plaintiffs lose, the litigation could have hard-to-predict effects on how employers, PBM and drug manufacturers will handle drug pricing arrangements in the future.

The parties: Braman is acting as the plaintiff in its case along with several affiliates: Braman Hyundai, Braman Cadillac, Braman Imports, Braman Palm Beach, Braman Automotive and Palm Beach Imports.

The defendants listed include the drug manufacturers Eli Lilly, Novo Nordisk and Sanofi Aventis U.S., and PBM and group purchasing organization affiliates of Cigna's Evernorth Health unit, CVS Health's Caremark unit and UnitedHealth's Optum Rx unit.

The allegations: Braman says the insulin makers, PBMs and GPOs use mechanisms such as acquisitions, trade groups and industry conferences to work together to drive up the list price of insulin and keep health plan sponsors and plan participants from getting the full value of any rebates or discounts that the PBMs and GPOs negotiate.

Braman notes in its complaint that it has 1,720 employees and dependents and spends about $200,000 per year on diabetes medications.

The company does not say how many of its plan participants have diabetes or how much it believes the defendants have cost it, but it presents Miami health data suggesting that about 10% of its plan participants could have diabetes.

The figures imply that Braman is spending about $100 per month on diabetes medications for plan participants with diabetes.

Braman presented data from sources such as a 2018 research paper suggesting that insulin makers could cut the price of insulin to about $4 to $12 per month and still make money.

Views: The co-lead counsel for the plaintiffs — Mark Pifko of Baron & Budd, Brandon Bogle of Levin Papantonio Rafferty, David Buchanan of Seeger Weiss and Ben Widlanski of Kozyak Tropin & Throckmorton — noted that the lawsuits name GPOs, or rebate negotiators, as defendants along the PBMs and insulin makers.

"By naming these rebate aggregators as defendants, our clients are shining a light on a practice they believe betrays their trust and unnecessarily inflates health care costs," the plaintiffs' lawyers said.

Eli Lilly said that, up until now, plaintiffs in insulin pricing suits have dropped their cases, lost motions to create class actions, or settled for nothing.

Lilly also rejected the Braman allegations.

"These copycat allegations are baseless," Lilly said. "As the complaint acknowledges, employers like the plaintiff hire PBMs to negotiate rebates, and benefit from and participate in the alleged conduct they now challenge."

Lilly has been working for years to reduce patients' out-of-pocket costs for insulin, and the average out-of-pocket cost for its insulin is just $17.16 per month, the company said.

Novo Nordisk said in a statement that the Braman allegations are "meritless."

"We intend to vigorously defend against these claims," the company said.  "While we will not comment further about pending litigation, we recognize that not all patient situations are the same and we have a number of different insulin affordability offerings available through NovoCare. Importantly, we continually review and revise our offerings as well as work with diverse stakeholders to create solutions for differing patient needs."

Optum Rx also rejected the Braman suit and similar suits.

"These baseless actions demonstrate a profound misunderstanding of how drug pricing works," the company said in a statement. "For many years, Optum Rx has aggressively and successfully negotiated with drug manufacturers and taken additional actions to lower prescription insulin costs for our health plan customers and their members, who now pay an average of less than $18 per month for insulin. PBMs, like Optum Rx, are the key counterweight to pharmaceutical companies' otherwise unchecked monopoly power to set and raise drug prices."

Sanofi declined to comment on the specifics of Braman's allegations.

"While we will not comment on the specifics of the allegations, Sanofi's pricing practices have always complied with the law, and the company is committed to helping patients access the medicine they need at the lowest possible price," the company said.

"Under the current system, savings negotiated by health insurance companies and PBMs through rebates are not consistently passed through to patients in the form of lower co-pays or coinsurance," Sanofi added. "As a result, patients' out-of-pocket costs continue to rise while — between 2012 and 2023 — the average net price of our insulins declined by 76%."

Representatives for CVS Health and Cigna were not immediately available to comment and have not yet appeared in court in connection with the Braman suit, but they have often rejected allegations similar to those in the Braman complaint in other MDL suits.

In March 2023, for example, the CVS Health and Cigna PBMs were part of a group of PBM defendants who objected to an insulin pricing suit filed by Kansas officials.

The plaintiff in that case tried to present rebate negotiations between PBMs and insulin manufacturers as part of an unlawful effort to inflate the price of insulin drugs, but "pharmaceutical rebates have been standard business practice for decades," and "they reflect hard-fought, competitive negotiations," the PBMs argued.

In September, Lars Fruergaard Jørgensen, the chief executive officer of Novo Nordisk, testified before a Senate committee that Novo Nordisk gets less revenue per insulin user in the United States than in some European countries because of the convoluted nature of the U.S. drug pricing and distribution system.