PBMs and access to prescriptions | Lawsuits abound against Express Scripts as parent company reports strong financial position

Russ O'Reilly, The Tribune-Democrat, Johnstown, Pa.Tribune-Democrat

JOHNSTOWN, Pa. – A decision last year by a global health company opened a chasm that still separates thousands of patients from a community pharmacy chain in Cambria, Somerset and Westmoreland counties.

A class-action lawsuit against the Cigna Group and its Evernorth Health Services division, including pharmacy benefit manager Express Scripts Inc., was filed in August on behalf of patients who have been cut off from Martella’s Pharmacy locations. The lawsuit has remained open.

Defendants also include Highmark and UPMC, who pay Express Scripts to manage their drug plans. When Express Scripts separated from Martella’s Pharmacy last year, those insurers deferred comment to Express Scripts.

The class action filed on behalf of Johnstown-area residents is one of many lawsuits against Cigna’s Express Scripts subsidiary.

Chicago, West Virginia

The multi-billion-dollar group foresees financial growth through 2026, following what Cigna reported as a strong financial year in 2025 – generating $274.9 billion in total revenue and $6 billion for shareholders’ net income, according to the Cigna Group’s Feb. 5 press release.

Aside from revenue generated from managing drug plans on behalf of insurers, PBMs have other ways of drawing funds, some of which are highlighted by a flurry of recent lawsuits against Express Scripts and its parent companies.

One lawsuit from a Chicago plumbers’ union alleges Express Scripts used its negotiating power with drug manufacturers to maximize its own profits rather than reduce the cost of drugs for its customers.

Drug companies must negotiate with PBMs to get their drugs on customers’ prescription plans. In exchange for their drug’s placement on a prescription plan, PBMs secure rebates, which PBMs say are used to reduce the cost of drugs for customers.

The Plumbers’ Welfare Fund filed a federal lawsuit Feb. 17 alleging Express Scripts and its corporate parents orchestrated a scheme to sell access to customers’ drug plans, keeping funds paid by drug manufacturers as fees instead of customer rebates.

Failing to pass rebates along to health care payers was among 29 findings of state law violations stemming from an examination of Express Scripts’ business practices by the West Virginia insurance commissioner.

The order is separate from another lawsuit filed by the West Virginia attorney general against Express Scripts and Evernorth in 2025. That lawsuit alleges violations of West Virginia and federal law, including dispensing opioids through Express Scripts’ own brand of mail-order pharmacies without adequate controls or oversight.

A spokesperson for the West Virginia attorney general said there is no update on that lawsuit.

The insurance commissioner’s examination found, in addition to rebate concerns, that the PBM failed in its role to fairly reimburse pharmacies for the cost of prescription drugs.

The West Virginia insurance commissioner issued a $1.5 million fine against Express Scripts in a March 2 order, which requires Express Scripts to address any violations and deficiencies identified in the examination report to bring itself in compliance with West Virginia law.

That order came about a month after the Federal Trade Commission announced a settlement against Express Scripts on Feb. 4. The FTC’s lawsuit alleged Express Scripts artificially inflated the list price of insulin drugs by using anticompetitive and unfair rebating practices.

Express Scripts avoided fines with that settlement, but is required to adopt changes to its business practices that “increase transparency, are expected to drive down patients’ out-of-pocket costs for drugs like insulin by up to $7 billion over 10 years, bring millions of dollars in new revenue to community pharmacies each year,” the FTC’s news release said.

The Wall Street Journal reported that Cigna Chief Executive David Cordani told analysts in a company earnings call following the FTC’s announced settlement that “all of the policy moves will leave the PBM’s margins, and its growth trajectory, largely unchanged.”