The Florida complaint also alleges that, as one of the “Big 3” PBMs, ESI can “leverage its market power” when negotiating with retail pharmacies. 

Two recent cases filed by state attorneys general allege collusion and fixing reimbursement rates among pharmacy benefit managers (PBMs), following on a trend of states asserting violations of antitrust laws.

Florida

On August 27, 2026, the Florida Office of the Attorney General filed a lawsuit against two PBMs for allegedly colluding in December 2019 to fix the price of reimbursement rates provided to Florida retail pharmacies.

The Florida complaint alleges that Express Scripts Inc. (ESI) and Prime Therapeutics LLC engaged in illegal price-fixing resulting in below-cost reimbursements provided by ESI and Prime to independent pharmacies in Florida. The reimbursement rates to Florida pharmacies for most brand and generic drugs filled for the PBM members forced many retail pharmacies to fill prescriptions at a loss which, ultimately, threatened their ability to remain in operation.

In the complaint, the Florida attorney general acknowledges the business realities that threaten the ability of PBM members to obtain necessary medication, including:

• PBMs compete against each other by seeking to be the exclusive PBM for a specific healthcare plan sponsor and enticing pharmacies to join their pharmacy network, which in turn helps them compete for exclusivity with plan sponsors.
• PBMs entice pharmacies via the number of “covered lives” (number of patient-members) PBMs serve and the reimbursement rates that are contractually offered to pharmacies that are part of a PBM’s pharmacy network.
• The reimbursement rates paid by PBMs directly impact whether the pharmacy makes a profit for dispensing a prescription or if a pharmacy dispenses that prescription at a loss.

The Florida complaint also alleges that, as one of the “Big 3” PBMs, ESI can “leverage its market power” when negotiating with retail pharmacies. The complaint alleges that ESI “leveraged its 100 million covered lives to obtain lower reimbursement rates for itself than smaller PBMs like Prime.” To compete with ESI to entice pharmacies to join Prime’s pharmacy network, Prime offered pharmacies higher reimbursement rates than ESI.

On December 19, 2019, ESI and Prime announced a “new three-year collaboration,” whereby ESI provides services to Prime related to its retail pharmacy network and pharmaceutical manufacturer contracts with an effective date of April 1, 2020. The Florida attorney general asserts that this “collaboration” was actually a horizontal price-fixing agreement by which Prime fixed its reimbursement rates to match ESI’s lower reimbursement rates.

According to the Florida complaint, Prime valued the first three years of its agreement with ESI at $2.5 billion in “cost reductions” extracted from pharmacies. The agreement allegedly made Prime more profitable, and Prime shared a portion of the “savings” with ESI. This agreement has allegedly continued to the present.

It is further alleged that, before the agreement, Prime’s reimbursement rates to independent pharmacies were approximately 20 percent higher than ESI’s reimbursement rates. After the agreement, Prime’s reimbursement rates declined to approximately 80 percent of branded drugs and 70 percent of generic drugs rates.

The Florida complaint alleges a per se violation of the Florida Antitrust Act as horizontal price-fixing and unfair methods of competition under the Florida Deceptive and Unfair Trade Practices Act. The Florida attorney general seeks injunctive relief, civil penalties, disgorgement, damages and other remedies.

Louisiana

On August 31, 2026, Louisiana’s Office of the Attorney General filed a similar lawsuit against ESI and its affiliate Ascent Health Services LLC, alleging that they unlawfully fixed reimbursement rates to independent pharmacies by, among other things, entering into an unlawful price-fixing agreement with Prime.

Complaints in Additional States

Like Florida and Louisiana, numerous other state attorneys general have filed multiple complaints against PBMs, asserting violations of antitrust laws, including:

• Iowa: In January 2026, the Iowa attorney general sued 18 PBMs and insulin manufacturers for artificially inflating and manipulating insulin prices.
• Michigan: In April 2025, the Michigan attorney general sued ESI and Prime alleging a conspiracy to suppress independent pharmacy reimbursements.
• Missouri: In January 2026, the Missouri attorney general sued 19 PBMs and drug manufacturers targeting an unlawful insulin pricing scheme.
• Oregon: In January 2026, the Oregon attorney general sued three PBMs—ESI, CVS Caremark and Optum—and drug manufacturers seeking $900 million for coordinated price inflation.
• Vermont: In July 2024, the Vermont attorney general sued Evernorth and CVS/Caremark for deceptively driving up prescription drug costs and violating consumer protection laws.

If the state attorneys general are successful against the PBMs, then the PBMs will likely be ordered to provide independent pharmacies with more appropriate reimbursements for the medications dispensed to PBM members. Further, the anticipated rulings may potentially support claims by independent pharmacies against PBMs to redress the artificially low reimbursement rates and to seek additional damages against the PBMs.

For More Information

If you have any questions about this Alert, please contact Jonathan L. Swichar, Sheila Raftery Wiggins, Bradley A. Wasser any of the attorneys in our Pharmacy Litigation Group or the attorney in the firm with whom you are regularly in contact.

Disclaimer: This Alert has been prepared and published for informational purposes only and is not offered, nor should be construed, as legal advice. For more information, please see the firm's full disclaimer.