Marion Diagnostic Center, LLC v. Becton Dickinson & Company

In the

United States Court of Appeals
For the Seventh Circuit
____________________
No. 21‐1513
MARION DIAGNOSTIC CENTER, LLC and
MARION HEALTHCARE, LLC,
Plaintiffs‐Appellants,

v.

BECTON DICKINSON & CO., CARDINAL HEALTH, INC., and
MCKESSON MEDICAL‐SURGICAL, INC.,
Defendants‐Appellees.
____________________

Appeal from the United States District Court for the
Southern District of Illinois.
No. 3:18‐cv‐01059 — Nancy J. Rosenstengel, Chief Judge.
____________________

ARGUED NOVEMBER 12, 2021 — DECIDED MARCH 18, 2022
____________________

Before SYKES, Chief Judge, and RIPPLE and ST. EVE,
Circuit Judges.
ST. EVE, Circuit Judge. A putative class of medical provid‐
ers brought this suit alleging a conspiracy to drive up the
prices of conventional syringes, safety syringes, and safety IV
catheters (“the Products”). The Providers’ First Amended
Complaint (“FAC”) alleged a hub‐and‐spokes conspiracy
2 No. 21‐1513

between manufacturer Becton, Dickinson & Co. (“BD”),
group purchasing organizations, and four distributors of the
Products in violation of the Sherman Act, 15 U.S.C. § 1. The
district court dismissed the FAC for failure to state a claim.
When we first considered this case on appeal, we agreed: the
Providers’ failure to allege that the distributors coordinated
with each other in furtherance of the conspiracy doomed their
claims on the merits. Marion Healthcare, LLC v. Becton Dickin‐
son & Co. (Marion I), 952 F.3d 832, 842–43 (7th Cir. 2020). None‐
theless, we vacated and remanded so the Providers could
amend their complaint one more time.
In their Second Amended Complaint (“SAC”), the Provid‐
ers abandoned their horizontal conspiracy allegations and
now allege two vertical conspiracies: (1) between BD and
McKesson Medical‐Surgical, Inc. (“McKesson”), and (2) be‐
tween BD and Cardinal Health, Inc. (“Cardinal”).1 The district
court once again dismissed the SAC for failure to state a claim.
The court also concluded that because the named plaintiffs do
not purchase the Products directly from Cardinal, they lack
“antitrust standing” to sue Cardinal under Illinois Brick Co. v.
Illinois, 431 U.S. 720 (1977). As explained below, we affirm.
I. Background
A. Allegations in the SAC
Marion Diagnostic Center, LLC and Marion Healthcare,
LLC are small healthcare providers in Marion, Illinois. Like
many such providers, they join group purchasing organiza‐
tions (“GPOs”), which negotiate contracts on behalf of their

1 According to Defendants, Plaintiffs erroneously named Cardinal Health,

Inc. as a Defendant. The relevant distribution entity is Cardinal Health
200, LLC.
No. 21‐1513 3

members for medical products. These GPO‐manufacturer
contracts are known as “Net Dealer Contracts.” GPOs present
the terms of the Net Dealer Contracts to providers, who can
either accept the terms or attempt to negotiate directly with a
manufacturer. If a provider accepts the terms of a Net Dealer
Contract, the provider then enters a “Distribution Agree‐
ment” with a distributor.2 Under this scenario, a provider
purchases medical products directly from a distributor, who
charges the prices agreed to in the Net Dealer Contract plus a
markup for the distributor’s services.
BD is the leading national manufacturer of the three prod‐
ucts at issue: BD controls 60% of the market for conventional
syringes, 60% of the market for safety syringes, and 55% of
the market for safety IV catheters. According to the Providers,
these products are commodities, meaning that they are effec‐
tively interchangeable with competitors’ products. Nonethe‐
less, BD charges significantly higher prices than its competi‐
tors: 11% more for conventional syringes, 36% more for safety
syringes, and 37% more for safety IV catheters.

2 The Providers argue that the Distribution Agreements often have one‐
sided termination clauses, meaning that distributors can terminate those
contracts, but providers cannot. Defendants object that the Providers in‐
appropriately supplemented the SAC through their brief opposing the
motion to dismiss. Compare Agnew v. Nat’l Collegiate Athletic Ass’n, 683 F.3d
328, 348 (7th Cir. 2012) (“[I]t is a basic principle that the complaint may
not be amended by the briefs in opposition to a motion to dismiss, nor can
it be amended by the briefs on appeal.”), with United States ex rel. Hanna v.
City of Chicago, 834 F.3d 775, 779 (7th Cir. 2016) (Rule 8 allows a plaintiff
to add facts to the complaint “by affidavit or brief—even a brief on ap‐
peal.”). Because this fact does not alter our analysis, we need not decide
whether the Providers raised it too late.
4 No. 21‐1513

Cardinal and McKesson are two of the largest distributors
of the Products. The distribution market entails warehousing,
processing orders, marketing, and tech support. Notably, the
Providers have not alleged that either Cardinal or McKesson
has market power in the distribution market, which includes
at least four major players. The Providers also concede that
they do not purchase BD products from Cardinal. They allege
only that they have purchased the Products from McKesson.
Complicating matters further, the Distributors make “Dealer
Notification Agreements” with BD, in which the Distributors
agree to distribute BD’s Products in accordance with the Net
Dealer Contracts.
Plaintiffs allege that BD is engaged in two vertical conspir‐
acies to restrain trade in the relevant product markets. Specif‐
ically, they allege that BD has a quid pro quo with Cardinal
and McKesson. First, the Net Dealer Contracts lock providers
into long‐term contracts for BD products through sole‐source
or dual‐source provisions, “penalty pricing” rebate provi‐
sions, and bundling. Second, Cardinal and McKesson enforce
those contracts, monitor providers’ compliance, and supply
BD with purchasing information, going above and beyond
the terms of the Distributors’ contractual obligations to BD.
Third, Cardinal and McKesson coerce providers into buying
only BD products through alleged misrepresentations about
the quality or availability of competitors’ products, even
when doing so is inconsistent with their own self‐interest.
Cardinal, for example, allegedly promotes BD’s products over
its competing in‐house brand, Covidien. Fourth, BD rewards
these Distributors with various incentives.
The Providers allege that BD has engaged in other anti‐
competitive acts in furtherance of the conspiracies. Namely,
No. 21‐1513 5

BD has made false claims about its own products while dis‐
paraging the products of its rival, Retractable, and BD has
been found liable for infringing Retractable’s patents. Addi‐
tionally, BD has entered exclusionary contracts with large
healthcare providers (outside the GPO system) that bundle
the three products at issue with other BD products. These al‐
legations appeared in the FAC, which this court previously
held failed to state a claim. Marion I, 952 F.3d at 842–43.
According to the Providers, all of this conduct amounts to
antitrust injury by allowing BD to inflate the prices of the
Products above competitive levels. The SAC further alleges
that the conspiracies harm innovation in the relevant product
markets by deterring potential entrants, thereby reducing
product quality and safety.
B. Dismissal of the FAC
In the FAC, the Providers alleged a hub‐and‐spokes con‐
spiracy between BD, Cardinal, McKesson, two other distribu‐
tors, and two GPOs in violation of the Sherman Act, 15 U.S.C.
§ 1.3 The district court dismissed the FAC based on a misap‐
plication of Illinois Brick Co. v. Illinois, 431 U.S. 720 (1977). In
Illinois Brick, the Supreme Court held that a direct purchaser
from an alleged monopolist or cartel member is the proper
party to bring suit; by contrast, indirect purchasers further
down the supply chain may not bring suit, even if they pay

3 Technically, the Providers’ cause of action is rooted in the Clayton Act,
not the Sherman Act. Section 4 of the Clayton Act provides that “any per‐
son who shall be injured in his business or property by reason of anything
forbidden in the antitrust laws may sue ... and shall recover threefold the
damages by him sustained.” 15 U.S.C. § 15(a).
6 No. 21‐1513

higher prices as a result of an upstream defendant’s anticom‐
petitive conduct. Id. at 728–29.4
This court has recognized a conspiracy “exception” to Illi‐
nois Brick, in which plaintiffs who purchase from one member
of an antitrust conspiracy may bring suit against any member
of the conspiracy. See Paper Sys., Inc. v. Nippon Paper Indus.,
Co., 281 F.3d 629, 631–32 (7th Cir. 2002).5 In Paper Systems, pa‐
per distributors sued five manufacturers of thermal facsimile
paper, alleging that the manufacturers had engaged in a hor‐
izontal price‐fixing conspiracy among themselves, as well as
vertical conspiracies with two trading firms (middlemen).
The plaintiffs purchased directly from two of the manufactur‐
ers and indirectly from two other manufacturers via the trad‐
ing firm defendants, so there was no question that the plain‐
tiffs could sue those defendants. A fifth manufacturer, Nip‐
pon Paper, sold its product to distributors who were not al‐
leged to be part of the conspiracy. The court explained that,
even though the plaintiffs did not purchase directly from Nip‐
pon, they could sue Nippon under Illinois Brick because Nip‐
pon was allegedly part of the same conspiracy as the four
other manufacturers and two trading firms. Paper Systems’

4 The facts of Illinois Brick offer a useful illustration. There, the State of
Illinois sued Illinois Brick, a manufacturer of concrete blocks, alleging that
Illinois paid more for the concrete blocks than it would have absent a
price‐fixing conspiracy. Illinois Brick sold the blocks to masonry contrac‐
tors, who sold them to general contractors, who sold their services to the
State of Illinois. Because the State had not purchased the blocks directly
from Illinois Brick, the State was not the proper party to bring suit.
5Other circuits have reached the same conclusion. See Insulate SB, Inc. v.
Advanced Finishing Sys., Inc., 797 F.3d 538, 542 (8th Cir. 2015); Lowell v. Am.
Cyanamid Co., 177 F.3d 1228, 1229–31 (11th Cir. 1999); Arizona v. Shamrock
Foods Co., 729 F.2d 1208, 1211–13 (9th Cir. 1984).
No. 21‐1513 7

interpretation of Illinois Brick reinforces the principle that an‐
titrust liability is joint and several, meaning that each member
of a conspiracy may be held liable for all of the damages
caused by the conspiracy. Id.
Returning to the FAC in this case, the district court incor‐
rectly believed that the conspirator “exception” to the direct‐
purchaser rule was limited to price‐fixing conspiracies. See
Marion Diagnostic Ctr., LLC v. Becton, Dickinson, & Co., No. 18‐
CV‐01059‐NJR‐RJD, 2018 WL 6266751, at *4 (S.D. Ill. Nov. 30,
2018). The FAC alleged that a web of contracts allowed BD to
charge supracompetitive prices, not that BD conspired with
the distributors and GPOs to fix prices for the Products. Be‐
cause Plaintiffs were not alleging a traditional price‐fixing
conspiracy, and because “[a]pportioning overcharges in this
case would lead to the complexities Illinois Brick sought to
avoid,” the district court concluded that they were not direct
purchasers and therefore could not bring suit against BD. Id.
C. Marion I
On appeal, this court clarified that the conspiracy “excep‐
tion” to Illinois Brick is not limited to price‐fixing conspiracies.
See Marion I, 952 F.3d at 839. We explained that “it is better to
think of the right to sue co‐conspirators not as an exception to
Illinois Brick, but instead as a rule inhering in Illinois Brick that
allocates the right to collect 100% of the damages to the first
non‐conspirator in the supply chain.” Id. (citing Paper Sys., 281
F.3d at 631–32). We also observed: “Apple [v. Pepper] confirms
that Illinois Brick is a bright‐line rule allocating the right to sue
to direct purchasers alone …. The relationship between the
buyer and the seller, rather than the nature of the alleged an‐
ticompetitive conduct, governs whether the buyer may sue
under the antitrust laws.” Id. at 840 (citing 139 S. Ct. 1514, 1522
8 No. 21‐1513

(2019)). The court concluded that the Providers could sue the
distributors under Illinois Brick because the distributors were
allegedly conspirators with BD. Marion I, 952 F.3d at 840–41.
Turning to the sufficiency of the complaint, however, the
Marion I court held that the Providers had failed to allege a
plausible hub‐and‐spokes conspiracy. Id. at 843. We noted:
“The role of the distributors is critical to the Providers’ case.
… If the distributors were not part of the alleged conspiracy,
then [the] Providers’ case falls apart: no conspiracy, no direct
purchaser status, no right to recover.” Id. at 841. To plausibly
allege an antitrust conspiracy, the Providers needed to show
that “the manufacturer and others had a conscious commitment
to a common scheme designed to achieve an unlawful objec‐
tive.” Id. (emphasis added) (quoting Monsanto Co. v. Spray‐
Rite Serv. Corp., 465 U.S. 752, 768 (1984)).
The FAC failed to state a claim because the Providers did
not allege that the distributors (the “rim”) coordinated with
each other at the direction of BD (the “hub”). Marion I, 952
F.3d at 842–43. Instead, the FAC alleged only that the distrib‐
utors enforced the Net Dealer Contracts between BD and the
GPOs and charged a fee for the distributors’ services. The Pro‐
viders did not even allege that the distributors knowingly en‐
gaged in parallel conduct, which could have constituted cir‐
cumstantial evidence of an agreement.6 Id. “All the Providers
have alleged is that the distributors buy and sell the devices
in accordance with the terms of the contracts that the GPOs

6 Independent action does not violate Section 1 of the Sherman Act. See
Monsanto, 465 U.S. at 760; Bell Atl. Corp. v. Twombly, 550 U.S. 544, 553–54
(2007) (citing Theatre Enters., Inc. v. Paramount Film Distrib. Corp., 346 U.S.
537, 540 (1954)).
No. 21‐1513 9

have negotiated.” Id. at 843. “They have made no argument
that the distributors played any role in setting the anticom‐
petitive pricing or that there was any quid pro quo according
to which Becton compensated them for participating in the al‐
leged antitrust conspiracy.” Id. We vacated and remanded so
that the Providers could file an amended complaint, “pro‐
vided that they believe they can adequately plead that the dis‐
tributors were part of the putative conspiracy.” Id.
D. Dismissal of the SAC
On remand, the Providers narrowed their allegations in
the SAC to two vertical conspiracies between (1) BD and Car‐
dinal, and (2) BD and McKesson. In other words, the Provid‐
ers dropped their allegations against the GPOs and two other
distributors, and the Providers no longer allege a horizontal
conspiracy among the remaining distributors. BD, Cardinal,
and McKesson all moved to dismiss the SAC for failure to
state a claim. The Distributors further argued that the Provid‐
ers lacked Article III standing to sue Cardinal because the Pro‐
viders purchased the Products only from McKesson.
The district court agreed with the Defendants and dis‐
missed the case. Marion Diagnostic Ctr., LLC v. Becton, Dickin‐
son & Co., No. 3:18‐CV‐1059‐NJR, 2021 WL 961728 (S.D. Ill.
Mar. 15, 2021). Relying on Weit v. Continental Illinois National
Bank & Trust Co., 641 F.2d 457 (7th Cir. 1981), the district court
concluded that both Article III and Illinois Brick’s direct‐pur‐
chaser rule require the Providers to show a “sufficient nexus
between the defendant’s alleged actions and an injury to
plaintiffs.” Id. at 469. The Providers failed to meet this stand‐
ard, in the district court’s view, because any alleged injury
from Cardinal’s anticompetitive activity was “vague and ten‐
uous.” Marion Diagnostic Ctr., 2021 WL 961728, at *2.
10 No. 21‐1513

Even if the Providers had standing to sue Cardinal, the
district court concluded they had failed to allege that BD and
the Distributors had “a conscious commitment to a common
scheme.” Monsanto, 465 U.S. at 768. The court summarized six
key allegations and sorted them into two categories: factors
showing quid pro quo, and factors showing conscious com‐
mitment. The court concluded that the following allegations
were insufficient to show quid pro quo: the Distributors’ sales
staff receive bonuses and other incentives, the Distributors re‐
ceive higher distribution fees, and the Distributors benefit
from guaranteed purchasing volume from long‐term con‐
tracts. These allegations are essentially recycled from the
FAC, which this court already held was insufficient to state a
claim in Marion I.
The district court then concluded that the following alle‐
gations were insufficient to show conscious commitment:
BD’s dominant market share facilitates collusion and there are
high barriers to entry; the Distributors’ actions are “contrary
to their self‐interest” because they should naturally prefer up‐
stream competition; the Distributors’ contracts with BD in‐
clude agreements to exclude BD’s rivals; the Distributors have
the motive to conspire because of BD’s dominance in the mar‐
ket; and the Distributors frequently communicate with BD
“beyond what is necessary to merely buy and sell products.”
Because the district court concluded that the SAC failed to
state a claim, the court did not address Defendants’ related
argument that the Providers failed to allege Cardinal or
McKesson had market power in the distribution market. The
Providers timely appealed.
No. 21‐1513 11

II. Discussion
This court reviews the district court’s dismissal for failure
to state a claim de novo. McGarry & McGarry, LLC v. Bankr.
Mgmt. Sols., Inc., 937 F.3d 1056, 1062 (7th Cir. 2019). More
specifically, we take a fresh look at the district court’s
conclusions that the Providers (1) lack standing to sue
Cardinal and (2) failed to state a Section 1 conspiracy claim.
Id. at 1062–63.
A. Standing
All agree that the Providers have standing to sue
McKesson and BD. The Providers contend that they also have
standing to sue Cardinal, even though they did not purchase
the Products from Cardinal.
Article III limits federal courts’ jurisdiction to “cases” and
“controversies.” U.S. Const. art. III, § 2. The “irreducible con‐
stitutional minimum” of standing requires that the plaintiff
has “(1) suffered an injury in fact, (2) that is fairly traceable to
the challenged conduct of the defendant, and (3) that is likely
to be redressed by a favorable judicial decision.” Spokeo, Inc.
v. Robins, 136 S. Ct. 1540, 1547 (2016). This court has recog‐
nized that “financial injuries are prototypical of [Article III]
injuries,” meaning that paying inflated prices due to an anti‐
competitive scheme will satisfy injury‐in‐fact. McGarry &
McGarry, 937 F.3d at 1063 (alteration in original); see also Loeb
Indus., Inc. v. Sumitomo Corp., 306 F.3d 469, 480–81 (7th Cir.
2002) (“There is no dispute that the plaintiffs in these cases
have been injured by paying an inflated price for copper; their
Article III standing is therefore secure.”).
The Providers argue that the district court “hopelessly
confused Article III standing and antitrust ‘standing’
12 No. 21‐1513

doctrine” when it concluded that the Providers lack standing
to sue Cardinal. The district court’s opinion did not cite Arti‐
cle III, but it did observe that the “general standing” and “an‐
titrust injury” inquiries “may overlap considerably.” Marion
Diagnostic Ctr., 2021 WL 961728, at *2 (citing Weit, 641 F.2d at
469).
In Weit, a putative class of credit card holders alleged that
five banks were engaged in a horizontal conspiracy to fix
credit card interest rates, as well as vertical conspiracies with
smaller “correspondent banks.” Weit, 641 F.2d at 459. This
court affirmed the district court’s grant of summary judgment
in favor of defendants on both the horizontal conspiracy
claims and the vertical conspiracy claims. Id. at 466, 468–69.
We then addressed whether plaintiffs had standing to assert
a vertical conspiracy claim against one bank (Pullman), even
though none of the named plaintiffs had Pullman credit cards,
because the district court had dismissed Pullman solely for
lack of standing. Id. at 469. We cited Illinois Brick in passing
for the proposition that plaintiffs must show a direct “anti‐
trust injury,” rather than for the direct‐purchaser rule.7 Id.

7 Antitrust injury and antitrust standing are related but distinct concepts.
The canonical case on antitrust injury is Brunswick v. Pueblo Bowl–O–Mat,
not Illinois Brick. See Brunswick Corp. v. Pueblo Bowl–O–Mat, Inc., 429 U.S.
477, 487–89 (1977) (holding that mere economic loss does not amount to
an antitrust injury under the antitrust laws). In Brunswick, bowling alley
operators alleged that a competitor hurt their businesses by acquiring
struggling bowling alleys that otherwise would have gone bankrupt. The
Supreme Court rejected their theory of antitrust liability, reiterating that
the antitrust laws protect “competition not competitors.” Id. at 488. “The
antitrust injury requirement ensures that a plaintiff can recover only if the
loss stems from a competition‐reducing aspect or effect of the defendant’s
behavior.” Atl. Richfield Co. v. USA Petroleum Co., 495 U.S. 328, 344 (1990).
No. 21‐1513 13

Without discussing Article III, the court concluded that plain‐
tiffs were unable to establish a “nexus” between the alleged
Pullman conspiracy and any injury to plaintiffs. Id.
The district court’s reliance on Weit was admittedly impre‐
cise. The Providers correctly note that Cardinal asked the dis‐
trict court to dismiss on the basis of Article III standing, not
antitrust standing. The Distributors respond that the district
court properly concluded the Providers’ alleged injury (in‐
flated prices for BD products purchased from McKesson) was
not fairly traceable to Cardinal’s alleged conduct (a vertical
conspiracy with BD). As explained below, we agree with the
Distributors that the Providers lack standing to sue Cardinal
under both Article III and Illinois Brick. At the same time, we
take this opportunity to clarify the distinction between the
two doctrines, even when they point in the same direction.
1. Article III
The Providers rely on cases like Loeb Industries, Inc. v. Su‐
mitomo Corp. and Sanner v. Board of Trade of City of Chicago to
argue that they have satisfied Article III standing.8 The plain‐
tiffs in Loeb purchased copper on the cash market and alleged
that copper merchants and brokers conspired to manipulate
the price of copper on the futures market. The court held that
plaintiffs had Article III standing to sue, even though the buy‐
ers were not participants in the copper futures market,

8 The Providers also cite McGarry & McGarry, LLC v. Bankruptcy Manage‐
ment Solutions, Inc., 937 F.3d 1056 (7th Cir. 2019), but that case is distin‐
guishable. 937 F.3d 1056, 1063, 1065–66 (7th Cir. 2019) (concluding that
plaintiff had “just barely” pleaded sufficient facts for Article III injury‐in‐
fact, and in any event, plaintiff did not allege the type of injury the anti‐
trust laws were meant to prevent).
14 No. 21‐1513

because the defendants’ alleged conduct influenced the price
of copper on the cash market. Loeb, 306 F.3d at 480–81.
Similarly, in Sanner, a group of soybean farmers alleged
that a conspiracy between the Chicago Board of Trade and
several individuals had artificially suppressed the price of
soybean futures, causing the farmers to sell their soybeans at
correspondingly low prices on the cash market. 62 F.3d 918,
921 (7th Cir. 1995). This court held that the farmers had Article
III standing because their injury was fairly traceable to the al‐
leged conspiracy. Id. at 924–25, 927–30. As in Loeb, it was irrel‐
evant that the farmers were not participants in the soybean
futures market because the conspiracy caused them harm
when it came time to sell their soybeans. Id. at 929 (“Since one
market tends to move in lockstep with the other, participants
in the cash market can be injured by anticompetitive acts com‐
mitted in the futures market.”).
We agree that the Providers have sufficiently alleged an
injury‐in‐fact in the form of higher prices for BD’s products,
but they have not shown that their injury is fairly traceable to
Cardinal’s conduct. According to the Providers, Loeb and San‐
ner recognize that “a plaintiff has standing simply if it buys
products at market prices affected by the defendants’ con‐
duct, even if that conduct occurred in a separate market.” This
broad interpretation would eviscerate Illinois Brick’s direct‐
purchaser rule because plaintiffs could always argue that an
upstream conspirator’s conduct resulted in higher prices
downstream.
Moreover, this case is distinguishable from Loeb and San‐
ner because the Providers have not alleged that the price of
the three BD Products is readily determinable outside the con‐
text of contract negotiations between the GPOs and BD.
No. 21‐1513 15

Syringes and catheters are not like soybeans and copper be‐
cause the prices of medical products are not listed on a com‐
modity exchange. The SAC itself alleges that prices vary de‐
pending on terms in the Net Dealer Contracts regarding bun‐
dling, long‐term discounts, penalty‐pricing rebate provisions,
and so forth.
We also note that the Providers cannot “piggy‐back on the
injuries of the unnamed class members” who may have pur‐
chased BD products from Cardinal. Payton v. County of Kane,
308 F.3d 673, 682 (7th Cir. 2002) (“Standing cannot be acquired
through the back door of a class action.”); see also TransUnion
LLC v. Ramirez, 141 S. Ct. 2190, 2208 (2021) (“Every class mem‐
ber must have Article III standing in order to recover individ‐
ual damages.”).9
2. Direct‐Purchaser Status
In addition to satisfying Article III standing, the Providers
must show that they have suffered an antitrust injury and that
they are the proper parties to bring suit. We assume for pur‐
poses of this analysis that the Providers have suffered an an‐
titrust injury because they are allegedly paying higher prices
for BD’s products than comparable products sold by compet‐
itors.10 The relevant question here is whether the Providers
are the proper party to bring suit for that injury.

9 Furthermore, if the litigation were to proceed to the class certification
stage, the Providers would not be adequate representatives of medical
providers that purchase the Products from Cardinal. See Fed. R. Civ. P.
23(a)(4).
10 Cf. Chi. Studio Rental, Inc. v. Ill. Dep’t of Commerce, 940 F.3d 971, 978–79
(7th Cir. 2019) (concluding that plaintiff film studio “has pleaded an injury
to itself, not an anticompetitive injury to the market”).
16 No. 21‐1513

To recap, in Illinois Brick, the Supreme Court held that a
direct purchaser from an alleged monopolist or cartel mem‐
ber is the proper party to bring suit; by contrast, indirect pur‐
chasers further down the supply chain may not bring suit,
even if they pay higher prices as a result of the defendant’s
anticompetitive conduct. 431 U.S. at 729. This court has inter‐
preted Illinois Brick such that a direct purchaser may sue any
member of an alleged antitrust conspiracy, so long as the
plaintiff is a direct purchaser from at least one member of the
conspiracy. See Paper Sys., 281 F.3d at 631–32; Marion I, 952
F.3d at 839.
The Providers are direct purchasers from McKesson,
which is allegedly in a vertical conspiracy with BD. The prob‐
lem here is that the Providers amended their complaint such
that they are no longer alleging a horizontal conspiracy be‐
tween the Distributors. Instead, they now allege two independ‐
ent vertical conspiracies between BD and McKesson, on the
one hand, and BD and Cardinal, on the other. Given these al‐
legations, the Providers cannot sue Cardinal under Illinois
Brick because the SAC makes clear that they do not purchase
BD Products from Cardinal.
The Providers claim that they “pay supracompetitive
prices for Becton Products whether they buy from Cardinal,
McKesson, another distributor, or Becton itself.” But the SAC
does not allege that all distributors are in the same conspiracy;
rather, the allegations are limited to Cardinal and McKesson,
just two of at least four major distributors. This discrepancy is
significant because the Providers do not allege that either Car‐
dinal or McKesson has market power in the distribution mar‐
ket. Without market power, it is hard to understand how Car‐
dinal or McKesson would be able to raise prices on BD’s
No. 21‐1513 17

products without losing business to other distributors. As this
court made clear when ruling on the sufficiency of the FAC,
“the first buyer from a conspirator is the right party to sue.”
Marion I, 952 F.3d at 836 (quoting Paper Sys., 281 F.3d at 631).
Because the Providers are no longer alleging a horizontal con‐
spiracy among the Distributors, the so‐called conspirator ex‐
ception outlined in Paper Systems is inapplicable.
Our conclusion aligns with the general principal that anti‐
trust conspiracy liability is joint and several. See Paper Sys.,
281 F.3d at 631–32. If Cardinal is not part of the BD‐McKesson
conspiracy, and Plaintiffs are not purchasing the Products
from Cardinal, then it does not make sense to hold Cardinal
liable, either for the BD‐McKesson conspiracy or for the BD‐
Cardinal conspiracy.
***
To summarize, the Article III and Illinois Brick inquiries
lead to the same outcome in this case: the Providers are not
the proper parties to bring suit against Cardinal. But the in‐
quiries remain distinct and serve different purposes. The Pro‐
viders cannot sue Cardinal under Article III because their in‐
jury is not fairly traceable to Cardinal’s conduct. They also
cannot sue Cardinal under Illinois Brick, as interpreted by this
court in Paper Systems, because they do not purchase the Prod‐
ucts from either member of the BD‐Cardinal conspiracy.
B. Failure to State a Claim
Because the Providers lack standing to sue Cardinal, our
analysis of the merits focuses on the remaining alleged verti‐
cal conspiracy between BD and McKesson. The district court
properly dismissed the SAC for failure to state a claim. We
begin with an overview of the legal standards governing
18 No. 21‐1513

vertical restraints of trade and then explain why the SAC falls
short.
1. Vertical Restraints
Section 1 of the Sherman Act prohibits “[e]very contract,
combination in the form of trust or otherwise, or conspiracy,
in restraint of trade or commerce among the several States.”
15 U.S.C. § 1. Courts have long recognized that Section 1 pro‐
hibits only unreasonable restraints of trade. See generally Stand‐
ard Oil Co. v. United States, 221 U.S. 1 (1911). Horizontal price‐
fixing agreements between competitors are classic per se vio‐
lations of Section 1, meaning that they are presumed unlaw‐
ful. See, e.g., Texaco Inc. v. Dagher, 547 U.S. 1, 5 (2006). By con‐
trast, vertical restraints are analyzed under the fact‐specific
rule of reason. See Cont’l T.V., Inc. v. GTE Sylvania Inc., 433 U.S.
36, 58–59 (1977) (holding that vertical nonprice restraints are
subject to the rule of reason); Leegin Creative Leather Prods., Inc.
v. PSKS, Inc., 551 U.S. 877, 882 (2007) (holding that vertical
price restraints, including minimum resale prices, are subject
to the rule of reason).
Under the rule of reason, “the factfinder weighs all of the
circumstances of a case in deciding whether a restrictive prac‐
tice should be prohibited as imposing an unreasonable re‐
straint on competition.” GTE Sylvania, 433 U.S. at 49. Relevant
factors include the restraint’s history, nature, and effect; spe‐
cific information about the relevant business; and whether the
businesses involved have market power.11 The purpose of the

11 See, e.g., Copperweld Corp. v. Indep. Tube Corp., 467 U.S. 752, 768 (1984)
(equating the rule of reason with “an inquiry into market power and
market structure designed to assess [a restraint’s] actual effect”); Ill. Tool
Works Inc. v. Indep. Ink, Inc., 547 U.S. 28, 45–46 (2006) (holding that
plaintiffs alleging antitrust violation from tying arrangements involving a
No. 21‐1513 19

rule is to distinguish “between restraints with anticompetitive
effect that are harmful to the consumer and restraints stimu‐
lating competition that are in the consumer’s best interest.”
Leegin, 551 U.S. at 886.
Before this court can even apply the rule of reason analy‐
sis, it needs to resolve the threshold question whether the
SAC sufficiently alleges a vertical conspiracy between BD and
McKesson. In Monsanto Co. v. Spray‐Rite Service Corp., the Su‐
preme Court announced the following standard of proof for
vertical conspiracies: “there must be direct or circumstantial
evidence that reasonably tends to prove that the manufac‐
turer and others had a conscious commitment to a common
scheme designed to achieve an unlawful objective.” 465 U.S.
752, 768 (1984) (emphasis added). Two features of Monsanto
complicate its applicability to this case. First, the Monsanto
court was reviewing a jury verdict, so the Court did not opine
on the kinds of allegations necessary to state a claim. Second,
at the time that Monsanto was decided, vertical price‐fixing
(also referred to as resale price maintenance) was still per se
illegal. Today, the same conduct would be evaluated under
the rule of reason. See Leegin, 551 U.S. at 882 (overruling Dr.
Miles Med. Co. v. John D. Park & Sons Co., 220 U.S. 373 (1911)).
That being said, some language in Monsanto remains use‐
ful for analyzing the sufficiency of the SAC. In particular, the
Court noted: “[T]he fact that a manufacturer and its distribu‐
tors are in constant communication about prices and market‐
ing strategy does not alone show that the distributors are not
making independent pricing decisions. A manufacturer and

patented product must prove that a defendant has market power in the
tying product).
20 No. 21‐1513

its distributors have legitimate reasons to exchange infor‐
mation about the prices and the reception of their products in
the market.” Monsanto, 465 U.S. at 762. “Moreover, distribu‐
tors are an important source of information for manufactur‐
ers. In order to assure an efficient distribution system, manu‐
facturers and distributors constantly must coordinate their ac‐
tivities to assure that their product will reach the consumer
persuasively and efficiently.” Id. at 763–64. These passages
suggest that the Providers’ allegations regarding the Distrib‐
utors’ frequent communications with BD are not necessarily
indicative of collusion.
2. The SAC
To survive a motion to dismiss, a complaint must “state a
claim to relief that is plausible on its face.” Bell Atl. Corp. v.
Twombly, 550 U.S. 544, 570 (2007); see Fed. R. Civ. P. 8(a)(2).
We accept the factual allegations in the SAC as true and draw
all permissible inferences in favor of the Providers. Viamedia,
Inc. v. Comcast Corp., 951 F.3d 429, 454 (7th Cir. 2020). To state
a Section 1 claim, a plaintiff must allege that the defendant
“(1) entered into an agreement that (2) unreasonably restrains
trade in the relevant market and (3) caused the plaintiff an an‐
titrust injury.” Ass’n of Am. Physicians & Surgeons, Inc. v. Am.
Bd. of Med. Specialties, 15 F.4th 831, 833 (7th Cir. 2021).
The Providers contend that the district court was wrong to
separate their allegations into two groups: allegations tending
to show a “conscious commitment,” and allegations tending
to show quid pro quo. They argue that the district court
should have considered the SAC as a whole, and that doing
so would have led it to a different conclusion. The Providers’
fixation on the two categories of allegations is a red herring.
No. 21‐1513 21

The real question is whether the Providers’ new allegations
fare any better than those in the FAC.
Many of the Providers’ allegations are “recycled,” and we
already deemed those allegations insufficient in Marion I. The
Providers’ allegations regarding BD’s “other anticompetitive
acts,” for example, are essentially unchanged from the FAC.
Similarly, allegations regarding BD’s “rewards to the distrib‐
utors,” now offered as evidence of a quid pro quo, appeared
elsewhere in the FAC. The Providers previously alleged that:
(1) the fees distributors receive are tied to prices paid for BD
products (as negotiated with GPOs in the Net Dealer Con‐
tracts), (2) BD pays higher commissions to distributors than
its rival manufacturers, and (3) long‐term contracts provide
distributors with guaranteed purchasing volume. Those alle‐
gations also appear in SAC.
The Providers point to additional details in the SAC, in‐
cluding allegations that the Distributors receive not only com‐
missions, but also bonuses, gifts, vacations, and other perks,
thereby reducing the Distributors’ labor costs. We are skepti‐
cal that these incentives constitute sufficient circumstantial
evidence of a conspiracy, particularly because the incentives
are directed to frontline sales representatives. To participate
in a conspiracy, agents of a defendant must have “knowledge
of the principal’s unlawful objective” and “an intent to re‐
strain trade.” Phillip E. Areeda & Herbert Hovenkamp, Anti‐
trust Law: An Analysis of Antitrust Principles and Their Applica‐
tion ¶ 1474c (last updated Sept. 2021); see also id. (“The broker
who merely earns its commission … does not share a ‘con‐
scious commitment to a common scheme designed to achieve
an unlawful objective.’” (quoting Monsanto, 465 U.S. at 764)).
The SAC is silent on whether the Distributors’ sales
22 No. 21‐1513

representatives knew of any conspiracy, much less shared an
intent to participate in one.
The Providers added the following “new” allegations in
the SAC: that the Distributors go beyond their contractual ob‐
ligations by cutting off lines of credit, increasing delivery fees,
embedding sales staff with providers to monitor compliance
with exclusive‐dealing terms, and providing purchasing his‐
tory to BD but not to other manufacturers. It is “conceivable”
that McKesson took steps along these lines to encourage pro‐
viders to buy BD products. Twombly, 550 U.S. at 570. But as
the Defendants argue, those steps are just as consistent with
the Distributors’ rational, lawful self‐interest in encouraging
sales with a leading manufacturer. See id. at 554.
The primary obstacle for the Providers is that they have
narrowed their allegations from a hub‐and‐spokes conspiracy
to two vertical conspiracies. The Providers have also dropped
their allegations against two other distributors and the GPOs.
In other words, they now need to show that vertical conspir‐
acies involving just two distributors and BD could plausibly
influence the prices that the Providers pay for the Products,
regardless of which distributor they purchase from, and re‐
gardless of the fact that there are at least four major distribu‐
tors. In our view, this is simply not plausible. The Providers
have not included any allegations showing that McKesson is
unique in its attempts to encourage sales of BD products, or
that the benefits McKesson receives from selling BD products
differ from the benefits any other distributor would receive.12

12The only Cardinal‐specific allegation is that Cardinal promotes BD’s
products over those of its in‐house brand, Covidien. This allegation alone
No. 21‐1513 23

If other distributors receive the same benefits but are not al‐
leged to be conspiring with BD, then there is no basis to infer
the existence of a conspiracy between McKesson and BD.
The Distributors are also not involved in negotiating
prices for BD products in the Net Dealer Contracts—those ne‐
gotiations are solely between BD and the GPOs. The Distrib‐
utors benefit from a percentage markup of those prices if and
only if providers decide to purchase BD’s products from a
particular distributor. In that way, all distributors benefit in‐
directly from marketing BD products to providers because
they will make more money than if they sell another manu‐
facturer’s products. That does not mean, however, that
McKesson is conspiring with BD to raise prices. See Marion I,
952 F.3d at 839 (“[T]he manufacturer has an incentive to get
the best deal it can from its distributors, both in terms of price
and in terms of necessary services. … The manufacturer’s in‐
terests thus align with those of the consumer who buys from
the distributor, not with those of the distributor.”). Moreover,
the Providers have not convincingly explained why they can‐
not choose distributors who are not alleged to be conspiring
with BD.
The Providers cite Twombly’s plausibility standard repeat‐
edly, but the outcome in that case cuts against them. Twombly
demonstrates that courts should dismiss antitrust conspiracy
complaints for failure to state a claim when the allegations,
taken as true, could just as easily reflect innocent conduct or
rational self‐interest. See Twombly, 550 U.S. at 554 (noting that
parallel conduct is “consistent with conspiracy, but just as

is insufficient to move the needle, and more importantly, the Providers
lack standing to sue Cardinal.
24 No. 21‐1513

much in line with a wide swath of rational and competitive
business strategy unilaterally prompted by common percep‐
tions of the market”). Because the Providers have not plausi‐
bly alleged a vertical conspiracy between BD and McKesson,
we affirm the district court’s decision on that basis.
The district court declined to reach the Distributors’
alternative basis for dismissal—that the Providers failed to
allege Cardinal or McKesson has market power in the
distribution market. In light of our conclusion that the SAC
fails to state a claim, we decline to address this argument in
the first instance.
III. Conclusion
For the foregoing reasons, the district court’s grant of the
motion to dismiss is
AFFIRMED.