A series of class action lawsuits allege that Express Scripts, the pharmacy benefit manager owned by The Cigna Group, has been systematically steering patients away from independent and retail pharmacies and toward its own subsidiary mail-order and specialty pharmacies — where it charges dramatically higher prices. In one striking example, Express Scripts’ specialty pharmacy Accredo charged West Virginia taxpayers $4,300 for a month’s supply of abiraterone, a prostate cancer drug, when federal government pricing made the same drug available for just $39 plus a $10 dispensing fee — a markup of roughly 110 times the lower price.
The allegations span multiple lawsuits filed between late 2024 and early 2026, including a RICO racketeering case brought by Bernstein Litowitz Berger & Grossmann LLP, a specialty pharmacy class action filed by Loevy + Loevy, and a copay siphoning suit targeting Express Scripts’ SaveOnSP program. The Federal Trade Commission also secured a landmark settlement in February 2026 that could reduce patient out-of-pocket costs by up to $7 billion over the next decade.
Table of Contents
- How Did Express Scripts Allegedly Direct Patients to Its Own Mail-Order Pharmacy at Higher Cost?
- What Does the RICO Racketeering Lawsuit Allege About Rebate Manipulation?
- The Copay Siphoning Scheme and How It Targets Vulnerable Patients
- What Does the FTC Settlement Mean for Drug Pricing Going Forward?
- State Attorney General Actions Signal Growing Legal Pressure
- The Human Cost of Pharmacy Steering
- What Comes Next for PBM Reform and Patient Protections
- Frequently Asked Questions
How Did Express Scripts Allegedly Direct Patients to Its Own Mail-Order Pharmacy at Higher Cost?
The core allegation across multiple lawsuits is straightforward: Express Scripts used its position as a pharmacy benefit manager to funnel prescriptions to pharmacies it owns, then charged inflated prices for the drugs dispensed through those channels. According to the Loevy + Loevy class action filed January 6, 2025, Express Scripts forces patients to use its subsidiary Accredo exclusively for any medication classified as “specialty.” Patients have no choice in the matter. Once locked into Accredo, thousands of patients have reported week-long delays, cancelled orders, broken cold-chain deliveries, surprise bills, and hours-long customer service calls that somehow vanish from company records. These are patients battling cancer, multiple sclerosis, and organ-transplant rejection — people for whom a missed or delayed medication shipment is not an inconvenience but a medical emergency. The pricing disparities are not subtle. Court filings and investigative reports indicate that Express Scripts and Accredo upcharge on at least 23 drugs, with markups ranging from $109 per month to $12,000 per month.
On 17 of those drugs, the monthly markup exceeded $2,000. Critics allege that Express Scripts reimburses its own mail-order pharmacy at lavish rates while paying competing pharmacies so little that the reimbursement does not even cover their costs — a strategy that slowly forces independent pharmacies out of the market and concentrates more prescription volume in Express Scripts’ own facilities. The corporate structure makes this possible. Express Scripts operates under Evernorth Health, Inc., which is itself a subsidiary of The Cigna Group. Its pharmacy subsidiaries include Accredo for specialty drugs and Express Scripts Pharmacy for mail-order prescriptions. This vertical integration means the same company that decides which pharmacy a patient must use also profits when that patient fills a prescription at a higher price through its own subsidiary.
What Does the RICO Racketeering Lawsuit Allege About Rebate Manipulation?
On February 17, 2026, Bernstein Litowitz Berger & Grossmann LLP filed a RICO class action against Express Scripts, Cigna, and Evernorth on behalf of PBM customers. The lead plaintiff is the Plumbers’ Welfare Fund, which provides healthcare benefits for members of Chicago-based Plumbers Local 130. The lawsuit alleges an “elaborate, fraudulent scheme” through which Express Scripts collected “exorbitant” kickbacks and bribes from pharmaceutical manufacturers in exchange for favorable placement on its drug formulary — the list of medications a health plan will cover. The rebate manipulation allegedly worked through a subsidiary called Ascent Health Services, a Swiss-based entity owned by Cigna. According to the complaint, Express Scripts funneled billions of dollars in drug manufacturer rebates through Ascent to avoid sharing those rebates with the plan sponsors — employers, unions, and other organizations — that were contractually entitled to a share.
By routing money offshore through a complex corporate structure, Express Scripts allegedly kept rebate dollars that should have been passed along to reduce drug costs for plans and their members. The lawsuit brings five counts including RICO violations, breach of contract, breach of the implied covenant of good faith and fair dealing, and unjust enrichment. However, it is important to understand that a lawsuit filing is not proof that these allegations are true. Express Scripts and Cigna will have the opportunity to defend themselves, and RICO cases carry a high burden of proof. Plan sponsors considering whether to join or monitor this litigation should consult legal counsel, because the outcome could take years and the class definition may evolve as the case proceeds.
The Copay Siphoning Scheme and How It Targets Vulnerable Patients
filed on December 26, 2024, a separate class action targets Save On SP, LLC, Express Scripts, Inc., and Accredo Health Group Inc. over what plaintiffs describe as a copay siphoning scheme. The lawsuit alleges that these entities diverted “hundreds of millions, if not billions, of dollars” in copay assistance funding that was meant to help patients afford their medications. Here is how the alleged scheme works in practice. Many pharmaceutical manufacturers offer copay assistance programs for expensive medications, providing funds to cover all or part of a patient’s out-of-pocket costs.
According to the complaint, Express Scripts and its affiliates artificially inflated patients’ copays for certain targeted medications. This inflation triggered larger payments from the copay assistance programs — payments that Express Scripts and its subsidiaries then captured rather than passing along as genuine cost relief to patients. The net effect is that money earmarked to help a patient with cancer or a chronic autoimmune condition afford their treatment instead flows into the PBM’s revenue stream. This type of allegation is particularly concerning because it exploits a system designed to protect the most financially vulnerable patients — those taking expensive specialty drugs who cannot afford the full cost out of pocket. If the allegations prove true, it would mean that the safety net these patients relied on was being quietly drained by the very company managing their prescriptions.
What Does the FTC Settlement Mean for Drug Pricing Going Forward?
On February 4, 2026, the Federal Trade Commission announced a landmark settlement with Express Scripts over allegations that the company artificially inflated insulin list prices using anticompetitive rebating practices. The settlement is expected to reduce patient out-of-pocket costs by up to $7 billion over ten years, making it one of the most consequential PBM enforcement actions in U.S. history. The settlement imposes several structural changes on Express Scripts. The company must shift pharmacy reimbursement to a cost-plus model, which would bring millions in new revenue to community pharmacies that have long complained about below-cost reimbursement from PBMs. Express Scripts must also provide drug-level reporting and disclose payments made to brokers and consultants — a transparency requirement that could expose previously hidden financial relationships.
Most provisions carry a compliance deadline of 2027, while the transparency requirements and cost-plus reimbursement model must be in place by 2028. Notably, Ascent Health Services — the Swiss subsidiary at the center of the rebate routing allegations — must return its operations to the United States by 2028. Express Scripts will be subject to ten years of monitoring. The tradeoff to understand here is that while the FTC secured sweeping concessions, Express Scripts avoided paying direct fines. The National Community Pharmacists Association noted the significance of the concessions, but some consumer advocates have questioned whether the lack of financial penalties sends the right deterrent signal. For patients, the practical impact will depend on how quickly the cost-plus model takes effect and whether Express Scripts complies in substance rather than just in form.
State Attorney General Actions Signal Growing Legal Pressure
The federal lawsuits and FTC settlement are not the only legal threats facing Express Scripts. State attorneys general have begun filing their own antitrust actions, signaling that the legal pressure on PBMs is intensifying from multiple directions simultaneously. On April 28, 2025, the Michigan Attorney General filed an antitrust lawsuit against Express Scripts, Evernorth, and Prime Therapeutics, alleging that the companies’ vertical integration suppresses competition and steers patients to affiliated pharmacies at the expense of independent pharmacies and consumers.
Earlier, in March 2023, Ohio Attorney General Dave Yost sued Express Scripts, Prime Therapeutics, and five other entities, blaming them for contributing to exorbitant drug prices in the state. A warning for plan sponsors and employers: the growing patchwork of state-level litigation means that PBM practices found acceptable in one jurisdiction may be deemed illegal in another. Organizations that contract with Express Scripts or other large PBMs should review their agreements carefully and pay close attention to how their PBM handles rebate pass-throughs, pharmacy network steering, and specialty drug pricing. The regulatory landscape is shifting rapidly, and contracts signed even a few years ago may not reflect the legal realities of 2026 and beyond.
The Human Cost of Pharmacy Steering
Behind the legal filings and pricing data are real patients whose health care has been disrupted. The Loevy + Loevy class action, filed on behalf of nine individual plaintiffs, paints a picture of what happens when a specialty pharmacy prioritizes volume over patient care. Thousands of patients relying on Accredo for medications that treat cancer, multiple sclerosis, and organ-transplant rejection have reported delays stretching a week or longer, orders cancelled without explanation, medications requiring cold-chain storage arriving compromised, and surprise bills for drugs they believed were covered.
For a patient taking immunosuppressants to prevent organ rejection, a week-long delay is not a paperwork problem — it is a potential medical crisis. The complaint describes patients spending hours on the phone with customer service representatives, only to find that records of their calls had disappeared from company systems. When the pharmacy you are forced to use is also the one creating the problem, and you have no ability to take your prescription elsewhere, the power imbalance is total.
What Comes Next for PBM Reform and Patient Protections
The convergence of private class actions, FTC enforcement, and state attorney general lawsuits suggests that 2026 and 2027 will be pivotal years for pharmacy benefit manager regulation. The FTC settlement’s requirement that Express Scripts adopt a cost-plus reimbursement model by 2028 could fundamentally change how pharmacies are paid, and if the model proves effective, regulators may push to extend similar requirements to other PBMs. Congressional attention to PBM practices has also intensified.
The RICO case filed by BLB&G could produce discovery that reveals internal documents about rebate routing and formulary manipulation — documents that may fuel further legislative action. For consumers, plan sponsors, and independent pharmacies, the message is that the era of opaque PBM pricing may be ending, but the transition will be uneven and contested. Patients currently enrolled in plans managed by Express Scripts should document any instances of pharmacy steering, unexpected cost increases, or service failures, as this information could be relevant to ongoing litigation or future claims.
Frequently Asked Questions
What is a pharmacy benefit manager and why does it matter?
A pharmacy benefit manager, or PBM, is a company that acts as an intermediary between health insurers, drug manufacturers, and pharmacies. PBMs like Express Scripts manage drug formularies, negotiate rebates with manufacturers, and determine how much pharmacies get paid for dispensing medications. Because they sit at the center of the drug pricing chain, their practices directly affect what patients pay at the pharmacy counter.
Am I affected if my insurance uses Express Scripts?
Potentially, yes. If your health plan uses Express Scripts as its PBM and you have been required to fill prescriptions through Accredo or Express Scripts Pharmacy’s mail-order service — particularly for specialty medications — you may have paid more than you would have at an independent or retail pharmacy. Review your prescription costs and compare them against prices available through other channels such as GoodRx or your local pharmacy.
What does the FTC settlement mean for my insulin costs?
The FTC settlement is expected to reduce patient out-of-pocket costs by up to $7 billion over ten years, with a particular focus on insulin pricing. However, most provisions do not take effect until 2027, and the cost-plus reimbursement model is not required until 2028. Patients should not expect immediate price reductions but may see gradual changes as compliance deadlines approach.
Can I switch away from Accredo for my specialty medications?
That depends on your health plan’s rules. One of the central allegations in the Loevy + Loevy class action is that patients are forced to use Accredo exclusively for any drug classified as “specialty,” with no ability to choose a different pharmacy. If your plan restricts you to Accredo, contact your employer’s benefits department or your insurer to ask about alternative arrangements, particularly if you have experienced service failures.
How can I join or monitor these class actions?
For the BLB&G racketeering case, visit blbglaw.com for updates on class certification and participation. For the Accredo class action, visit loevy.com for information on the claims process. Class certification has not yet been granted in all cases, so check periodically for developments. You do not typically need to take action until a class is certified and a claims process is established.