Twelve Arkansas pharmacies sue Express Scripts over PBM pricing

The Arkansas case is the newest front in a set of challenges to how Express Scripts prices drugs [8][9][10][11]. That matters. For patients, the damages can exceed a single copay dispute [8]. For plan sponsors, the suits test pharmacy networks and reimbursement rates [9][10]. Express Scripts also faces a Federal Trade Commission settlement announced on 4 February 2026. The deal requires it to rewrite insulin pricing [1][4]. The FTC says it will save Americans up to $7 billion in out-of-pocket costs over 10 years [1][4].

What Express Scripts agreed to

The settlement resolves the FTC's lawsuit [1][4]. The agency alleged that Express Scripts, owned by Cigna, artificially inflated insulin prices and impeded access to the drug [1][4].

The terms go further. The company must stop listing preferred drugs at the high wholesale acquisition cost when lower-cost versions exist on its standard formularies [4]. It also has to offer a standard benefit design where patient out-of-pocket costs follow a drug's net cost rather than its list price [4]. Full access to its Patient Assurance Program goes to anyone whose plan covers insulin, unless the plan sponsor opts out [4]. Plan sponsors get a standard way to move off rebates or spread pricing. The terms also delink manufacturer payouts from list prices [4].

Ascent, the group purchasing organisation, moves to the United States from Switzerland [1][4]. The terms reach past insulin. Under the standard design, a patient's copay would follow what a drug costs after rebates, not the list price on the box [4]. Employers and unions get a standing route out of rebate and spread-pricing contracts. The FTC says that mechanism inflated insulin prices [4]. Take-up is the open question. The design is an option plan sponsors can decline. Neither the FTC nor Cigna has said how many will use it [4].

Why the rebate model is the target

The FTC's original complaint named Express Scripts alongside Optum Rx and CVS Caremark, the three largest PBMs [4]. It alleged their rebate system pushed drugmakers to compete for formulary placement on rebates rather than on net price [4].

Size explains why these terms travel. The three largest PBMs control nearly 80% of US prescriptions. Express Scripts holds the largest share of that market [5]. Cigna bought Express Scripts in 2018 for $67 billion. It now holds nearly 30% of the pharmacy benefit market [3]. Ownership runs deeper than the PBM. Cigna also owns specialty pharmacy Accredo, mail-order pharmacy Express Scripts Pharmacy and prior-authorisation manager eviCore, all inside Evernorth [3].

The price of settling

Express Scripts says the agreement is designed to ensure members pay the lowest cost for their prescriptions [4]. It announced in October that it would roll out a rebate-free model. The model is built on more transparency. Its leaders have said they expect a significant financial hit from that launch [4].

The FTC has run this play before. On 14 July 2026 it announced a parallel settlement with CVS Caremark [6]. The agency said that deal would save up to $8.5 billion over 10 years [6]. It would provide up to $4.5 billion more through pharmacy counter rebates [6]. That figure is larger than the $7 billion deal [1][6].

What happens next

The Express Scripts settlement is open for public comment for 30 days [4]. The FTC has not said whether it is pursuing similar agreements with Optum Rx and CVS Caremark. It also has not said where those conversations stand [4].

Ascent also sits at the centre of private litigation. A class action filed on 17 February 2026 in the Northern District of Illinois targets that arrangement [2]. Bernstein Litowitz Berger & Grossmann brought it [2]. The Plumbers' Welfare Fund is lead plaintiff [2]. The complaint alleges Express Scripts used the Swiss entity to book drugmaker payments as fees rather than rebates [2]. The class has not been certified [2].

State attorneys general have opened their own fronts. Louisiana Attorney General Liz Murrill sued Express Scripts and Ascent, according to a filing reported on 31 August 2026 [11]. The suit alleges the company steers patients to pharmacies it controls and coordinates fees with Prime Therapeutics [9][11]. It says Express Scripts oversees prescriptions for about 71% of Louisiana residents [9].

Florida Attorney General James Uthmeier sued Express Scripts and Prime, Fierce Healthcare reported on 28 August 2026 [10]. The complaint argues their 2019 partnership fixed prices [10]. It says Prime's reimbursement rates were about 20% higher before the deal [10].