The West Virginia attorney general asserts that ESI, as a PBM, held a “uniquely powerful position” within the “prescription drug ecosystem.”

On August 15, 2025, the state of West Virginia, via its Office of the Attorney General, 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.”

PBMs often act as intermediaries between insurance providers, drug manufacturers and pharmacies, negotiating discounts and rebates with manufacturers and reimbursing pharmacies for the prescriptions they fill on behalf of the insurance company.

The attorney general stated that ESI’s position as a PBM made it a “central architect” for the opioid epidemic while it ignored data readily available about the harms of widespread prescribing and the use of addictive opioids. Specifically, the lawsuit asserts that ESI violated West Virginia state law by:

• Conspiring with opioid manufacturers to deceptively market opioids to the public;
• Using rebates and fees to undermine clinical judgment and thus incentivize the increased sale and prescription of opioids;
• Reducing protocols, such as prior authorizations and quantity limits on the amount of opioids prescribed; and
• Dispensing opioids through mail-order pharmacies that allegedly lacked adequate controls or oversight to prevent overprescription.

West Virginia Joins Growing List of States Suing PBMs

Similar lawsuits have been filed against PBMs by three other states.

Michigan sued ESI and Prime Therapeutics LLC in April 2025 asserting that the PBMs made an unlawful agreement to suppress reimbursement rates to independent pharmacies, which contributed to the creation of a pharmacy desert in parts of Michigan and paid ESI’s pharmacies additional administrative fees.

Utah sued ESI and United Health Group in December 2024 asserting that the PBMs set up rebates and provided “preferred status” or opioids as prescription drugs and flooded the market with opioids which then flowed into an illegal, secondary market that resulted in devastating consequences for Utah.

Kentucky sued ESI, Medco Health Solutions, ESI Mail Pharmacy Service Inc. and Express Scripts Pharmacy Inc. in September 2024 asserting that the PBMs dispensed prescription opioids through their mail-order pharmacies without effective controls against diversion in violation of Kentucky law and federal laws and colluded with Purdue Pharma and other opioid manufacturers to restrict or eliminate utilization management tools on national formularies that would have limited opioid prescribing and/or dispensing.

These lawsuits concern alleged conduct by PBMs that occurred over the course of 10 to 20 years.

Considering the magnitude of recently filed complaints by state attorneys general against PBMs based on allegedly improper practices regarding their allowance of fills of opioids for their members, we anticipate that additional state attorneys general will likewise file similar lawsuits challenging PBMs’ practices and seeking monetary damages for the harm that the opioid crisis has inflicted on citizens and state benefit programs. 

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.

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