In late August 2026, the attorneys general of Florida and Louisiana filed separate lawsuits challenging alleged anticompetitive practices involving pharmacy benefit managers (PBMs) and an unlawful horizontal price-fixing agreement that allegedly suppressed pharmacy reimbursement rates. Florida sued Express Scripts, Inc. (ESI) and Prime Therapeutics LLC, while Louisiana sued ESI and its affiliate Ascent Health Services, LLC, alleging, among other things, anticompetitive conduct involving ESI’s agreement with Prime. These actions represent the latest escalation in a growing wave of state-level antitrust enforcement aimed at PBM reimbursement practices, with potentially significant implications for independent pharmacies nationwide.
Florida’s Complaint
On August 27, 2026, Florida Attorney General James Uthmeier filed suit against Prime Therapeutics and Express Scripts in the Circuit Court of the Tenth Judicial Circuit in Polk County. The complaint alleges that in December 2019, the two competing PBMs announced a “collaboration” under which Prime adopted Express Scripts’ significantly lower pharmacy reimbursement rates. The agreement took effect in April 2020 and remains in effect today.
The consequences for Florida’s pharmacies have been severe. According to the complaint, Prime’s reimbursement rates were roughly 20% higher than ESI’s prior to the agreement. After the arrangement took effect, reimbursement rates declined for approximately 80% of branded drugs and 70% of generic drugs. The complaint provides a striking example in which a pharmacy outside Orlando saw its reimbursement for a single drug drop 45%, transforming a profit into a $15.45 loss per prescription.
According to the Florida Attorney General, Prime valued the first three years of the arrangement at $2.5 billion in “cost savings” allegedly extracted from pharmacies. This action is separate from the Florida Attorney General’s earlier civil investigative demand issued in June 2026 concerning CVS Health and Caremark’s alleged anticompetitive practices.
Louisiana’s Complaint
Four days later, on August 31, 2026, Louisiana Attorney General Liz Murrill filed a federal complaint in the U.S. District Court for the Eastern District of Louisiana against Express Scripts and its affiliate group purchasing organization (GPO), Ascent Health Services, LLC.
Louisiana’s complaint is broader in scope than Florida’s. In addition to the allegations involving price-fixing allegations, Louisiana asserts that ESI controls prescription drug coverage for approximately 71% of Louisianians with commercial insurance and held about 86.71% of the state’s private PBM market in 2024.
The complaint alleges that ESI used this dominant market position to manipulate pharmacy reimbursement rates, conceal profits, and steer patients toward pharmacies it owns or controls. The state further alleges that ESI reimburses independent pharmacies at rates below acquisition cost and at lower rates than it pays its own affiliated pharmacies, findings consistent with the Federal Trade Commission’s prior reports on PBMs.
Building on Michigan’s Blueprint
Both the Florida and Louisiana complaints build on the framework established by Michigan’s Attorney General’s April 2025 federal lawsuit against Express Scripts, Evernorth Health, Inc., and Prime Therapeutics. Michigan’s complaint targeted the same December 2019 agreement and alleges violations of the Sherman Act, the Michigan Antitrust Reform Act, and public nuisance laws. The Michigan case remains in active litigation.
Oklahoma’s Precedent
Oklahoma’s enforcement actions against CVS Caremark provide further context for the current PBM enforcement landscape. In January 2025, the Oklahoma Attorney General filed suit in the state’s newly established PBM Administrative Court, alleging that Caremark reimbursed Oklahoma pharmacies below acquisition cost for hundreds of individual prescription claims in violation of state law. See 59 O.S. § 360(A)(4) and (A)(5). That case settled in December 2025 for $5.08 million, covering 68,099 below-cost prescription claims.
The settlement mandated operational reforms, including requirements that Caremark evaluate pharmacy challenges against national pricing benchmarks, accept documentation of actual acquisition costs, and comply with the statutory 10-calendar-day deadline for resolving disputes.
Rhode Island’s Lawsuit
In May 2025, Rhode Island Attorney General Peter Neronha sued CVS Caremark, Express Scripts, and OptumRx, along with their affiliated GPOs, alleging that they unfairly and deceptively increase prescription drug costs by exploiting opaque pricing structures and profiting from price increases throughout the drug supply chain. Rhode Island also concluded an enforcement action against Prime Therapeutics in February 2026 for alleged violations of the state’s Pharmacy Audit Act related to unannounced on-site audits of three independent pharmacies.
A Broader Pattern of State PBM Enforcement
Taken together, these actions reflect increased scrutiny by state attorneys general across the country of PBM reimbursement practices, including allegations of below-cost reimbursement and anticompetitive conduct. The Florida and Louisiana complaints join Michigan’s pending federal case in challenging conduct related to the 2019 “collaboration” that state regulators allege has harmed independent pharmacies and the patients they serve.
For independent pharmacies, these enforcement actions are a significant development. They reflect increased regulatory attention to allegations that below-cost reimbursement practices, opaque PBM contracting terms, and the anticompetitive effects of PBM consolidation and collaboration pose a direct threat to pharmacy viability and patient access.
Independent pharmacies experiencing similar reimbursement or contracting issues should consider documenting their experiences and evaluating whether to bring those concerns to appropriate state regulators. Depending on the applicable law and circumstances, pharmacies may also have potential avenues for direct legal action.
How Frier Levitt Can Help
Frier Levitt has represented pharmacies in disputes with PBMs for decades. Our attorneys regularly counsel independent pharmacies, regional chains, specialty pharmacies, and pharmacy associations on PBM audits, network terminations, reimbursement disputes, provider agreement negotiations, and state and federal regulatory matters. We have litigated cases against the nation’s largest PBMs, negotiated contract terms to protect pharmacy interests, filed regulatory complaints on behalf of pharmacies, and developed strategies to help pharmacies preserve their network participation while safeguarding their legal and financial rights.
If your pharmacy has experienced below-cost reimbursement, unfair audit practices, restrictive contract terms, or network termination threats, Frier Levitt’s attorneys can help evaluate the applicable contractual, regulatory, and litigation options. Contact us today if you believe a PBM may be failing to abide by its provider agreement or state regulations.
Senior Associate
