Multiple class action lawsuits and federal investigations allege that Express Scripts, one of the largest pharmacy benefit managers in the United States, manipulated its drug formularies to steer patients — including those battling cancer — toward higher-cost, non-preferred medications in exchange for manufacturer kickbacks. A February 2026 racketeering lawsuit filed by a Chicago-based healthcare fund accuses Express Scripts, its parent company Cigna, and subsidiary Evernorth of violating the RICO Act by diverting billions in drug rebates to a Swiss offshore entity while selling formulary placement to pharmaceutical companies and excluding lower-cost alternatives. For cancer patients who depend on specialty drugs like lenalidomide (Revlimid) for multiple myeloma, these formulary decisions are not abstract corporate maneuvers — they determine whether treatment is affordable or financially devastating.
The Federal Trade Commission reached a landmark settlement with Express Scripts on February 4, 2026, that is expected to reduce patients’ out-of-pocket drug costs by up to $7 billion over the next decade. The settlement requires Express Scripts to overhaul the way it builds formularies, ending practices that the FTC says artificially inflated list prices through anticompetitive rebating. Meanwhile, a separate class action targeting Express Scripts’ specialty pharmacy subsidiary, Accredo, documents cases where cancer patients experienced week-long delays in receiving oral chemotherapy medications, leading to emergency room visits and disease progression.
Table of Contents
- What Are the Class Action Claims That Express Scripts Required Non-Preferred Drugs in Cancer Patients’ Plans?
- How Express Scripts’ Rebate System Inflated Drug Costs for Patients
- The Accredo Specialty Pharmacy Crisis and Cancer Patient Harm
- What Cancer Patients Can Do Right Now to Protect Their Coverage
- The RICO Allegations and What They Mean for Plan Members
- How 2026 Formulary Exclusions Are Hitting Cancer Patients Now
- What Comes Next for Express Scripts and Cancer Drug Coverage
- Frequently Asked Questions
What Are the Class Action Claims That Express Scripts Required Non-Preferred Drugs in Cancer Patients’ Plans?
The most directly relevant case is the racketeering class action filed on February 17, 2026, in the U.S. District Court for the Northern District of Illinois (Case No. 1:2026cv01718). The plaintiff, Plumbers’ Welfare Fund, Local 130 U.A., alleges that Express Scripts “sold” formulary placement to drug manufacturers, demanding kickbacks in exchange for listing their drugs as preferred options. The complaint names Pfizer, Sanofi, Novo Nordisk, Novartis, and Johnson & Johnson as co-conspirators and brings five counts including RICO violations, breach of contract, breach of the implied covenant of good faith, and unjust enrichment. The law firm Bernstein Litowitz Berger & Grossmann filed the suit, alleging that Express Scripts diverted billions of dollars in drug rebates to Ascent Health Services, a Swiss-based offshore subsidiary, enriching itself at the expense of the health plans and patients it was supposed to serve.
No single class action uses the exact title “Express Scripts Required Non-Preferred Drugs for Cancer Patients’ Plans,” but the combined allegations across these cases describe precisely that mechanism. When a drug manufacturer offers Express Scripts a larger rebate on a higher-priced version of a medication, Express Scripts allegedly places that version on a preferred tier — even when a lower-cost alternative exists. The result for a cancer patient is straightforward: their plan’s formulary lists the expensive drug as “preferred” and either excludes the cheaper option entirely or places it on a tier with higher co-pays. The patient pays more, Express Scripts collects more in rebates, and the manufacturer moves more units of its high-margin product. For example, Express Scripts announced formulary changes effective January 1, 2026, that excluded Revlimid (lenalidomide) for new patient starts, with existing users phased out by April 1, 2026. Revlimid is a critical treatment for multiple myeloma and other blood cancers. When a drug like this is removed from a formulary or placed on a non-preferred tier, patients and their oncologists face the choice of switching therapies — sometimes to less effective alternatives — or absorbing dramatically higher out-of-pocket costs during active cancer treatment.
How Express Scripts’ Rebate System Inflated Drug Costs for Patients
The core of the FTC’s case against express scripts centers on a rebate structure that, according to the agency, inverted the incentives of a pharmacy benefit manager. Rather than negotiating the lowest possible net price for a medication, Express Scripts allegedly preferred manufacturers who offered the largest rebates off inflated wholesale acquisition costs (WAC). A manufacturer could set a high list price, offer Express Scripts a substantial rebate, and still receive more per unit than a competitor offering a genuinely lower price with a smaller rebate. Express Scripts captured the difference, while patient co-pays were calculated based on the inflated list price rather than the net cost after rebates. The FTC settlement imposes a specific structural fix: when a manufacturer offers both a high-WAC and a low-WAC version of a drug, Express Scripts cannot exclude the low-WAC version or place it on a less favorable tier while covering the high-WAC version. Additionally, member out-of-pocket costs must now be based on net cost, not list price.
These changes must be implemented no later than January 1, 2028. Express Scripts avoided monetary fines but agreed to what the FTC described as fundamental changes to its PBM business model. However, patients should understand that these reforms have a significant delay built in. The settlement was announced in February 2026, but the compliance deadline is nearly two years away. During that gap, existing formulary structures remain largely intact. If you are currently on a cancer treatment plan and your medication is on a non-preferred tier or has been excluded from your formulary, the FTC settlement does not provide immediate relief. You would need to work with your oncologist on a formulary exception request or explore manufacturer patient assistance programs while waiting for the structural changes to take effect.
The Accredo Specialty Pharmacy Crisis and Cancer Patient Harm
Accredo Health Group, Express Scripts’ in-house specialty pharmacy, handles medication fulfillment for patients with cancer, multiple sclerosis, organ transplant rejection, and other serious conditions. A class action lawsuit documents a pattern of failures that goes beyond formulary manipulation into basic fulfillment: week-long delays in processing refills, cancelled orders without notification, broken cold-chain deliveries that render temperature-sensitive biologics useless, surprise bills, and support calls that stretch for hours without resolution. For cancer patients specifically, the consequences of these failures are medically dangerous. Oral chemotherapy drugs like capecitabine or lenalidomide must be taken on precise schedules. When Accredo delays or fails to deliver these medications, patients have landed in emergency rooms, developed drug resistance from interrupted treatment cycles, or experienced measurable disease progression.
Unlike a delayed shipment of blood pressure medication — which carries its own risks — a gap in chemotherapy can permanently alter a patient’s prognosis and limit future treatment options. The Accredo situation illustrates an important distinction. The BLB&G racketeering case and the FTC settlement address systemic formulary manipulation — the question of which drugs are covered and at what cost. The Accredo class action addresses operational failures — the question of whether covered drugs actually reach the patient on time and intact. A cancer patient dealing with Express Scripts may face both problems simultaneously: a formulary that steers them toward a more expensive treatment and a specialty pharmacy that cannot reliably deliver it.
What Cancer Patients Can Do Right Now to Protect Their Coverage
If you are a cancer patient on an Express Scripts plan and your medication has been moved to a non-preferred tier or excluded from the formulary, the first step is to have your oncologist submit a formulary exception request, sometimes called a prior authorization appeal or medical necessity determination. This requires documentation that the prescribed drug is medically necessary for your specific condition and that alternative formulary drugs are either clinically inappropriate or have already been tried and failed. Success rates on these appeals vary, but they are significantly higher when supported by peer-reviewed evidence and detailed clinical notes. The tradeoff patients face is between fighting the formulary and switching medications. An appeal takes time — often weeks — and is not guaranteed to succeed. Switching to a formulary-preferred alternative may be clinically acceptable in some cases, but oncology treatment decisions are highly individualized.
A drug that works well in clinical trials may not be the right choice for a patient with specific comorbidities, prior treatment history, or genetic markers. Patients should not feel pressured to switch therapies purely for formulary reasons without a thorough discussion with their oncologist about clinical equivalence. The FTC settlement will eventually require Express Scripts to cover lower-cost drug versions when available, but until January 2028, patients must navigate the current system. State attorney general offices have also become increasingly active on PBM practices. Michigan’s attorney general filed a complaint against Express Scripts in April 2025, Vermont’s attorney general sued PBMs including Express Scripts in July 2024, and Ohio’s attorney general filed suit in March 2023. Patients in these states may have additional avenues for complaint or recourse through their state AG’s consumer protection division.
The RICO Allegations and What They Mean for Plan Members
The racketeering claims in the BLB&G lawsuit represent the most aggressive legal theory yet applied to PBM formulary practices. RICO — the Racketeer Influenced and Corrupt Organizations Act — was originally designed to combat organized crime, and its application to pharmacy benefit management signals how seriously the plaintiffs’ attorneys view the alleged conduct. The complaint alleges a pattern of racketeering activity: Express Scripts did not merely make poor business decisions but operated a systematic scheme to divert rebate money owed to health plans into an offshore subsidiary while selling formulary positions to the highest pharmaceutical bidder. If the RICO claims survive a motion to dismiss, the consequences for Express Scripts could be severe. RICO allows for treble damages — three times the actual financial harm — plus attorneys’ fees. For the Plumbers’ Welfare Fund and potentially thousands of similarly situated health plans, the damages could run into the billions.
However, RICO cases are notoriously difficult to prove. The plaintiffs must demonstrate a “pattern of racketeering activity” consisting of at least two predicate acts, and they must show that the defendants operated or managed an “enterprise” engaged in interstate commerce. Express Scripts will likely argue that its formulary decisions were legitimate business practices protected by contract terms with the health plans. Plan members should understand a limitation here: even if the RICO class action succeeds, individual patients are unlikely to receive direct compensation. The plaintiff is a health fund, and damages would flow to the plan level. The benefit to individual patients would be indirect — plans that recover diverted rebate money could potentially lower premiums, reduce co-pays, or expand formulary coverage. For direct relief on out-of-pocket costs, the FTC settlement’s structural reforms are more likely to produce tangible results for individual cancer patients.
How 2026 Formulary Exclusions Are Hitting Cancer Patients Now
Express Scripts’ 2026 formulary changes provide a concrete example of how exclusion decisions affect cancer treatment. Revlimid (lenalidomide), a standard-of-care drug for multiple myeloma, was excluded for new starts effective January 1, 2026. Patients already on the drug were given until April 1, 2026, to transition to alternatives.
Multiple myeloma patients who had been stable on Revlimid for months or years were forced to work with their oncologists to either secure an exception or switch regimens — during active cancer maintenance therapy. This type of mid-treatment disruption is exactly what the FTC settlement aims to prevent going forward. If a lower-cost version of lenalidomide exists, Express Scripts would be prohibited from excluding it in favor of a higher-WAC alternative under the new rules. But those rules do not take effect until 2028, leaving current patients to manage the transition with whatever tools are available now — exception requests, manufacturer copay assistance programs, or appeals through their employer’s benefits department.
What Comes Next for Express Scripts and Cancer Drug Coverage
The period between now and January 2028 will be critical. Express Scripts must design and implement a fundamentally different approach to formulary construction, one that prioritizes net cost over rebate value and passes savings through to patient co-pays. Whether this actually results in better cancer drug coverage depends on how aggressively Express Scripts complies and how the FTC monitors implementation. The agency secured structural reforms rather than fines, betting that changing the business model is worth more than a one-time penalty.
The BLB&G racketeering case, the state attorney general lawsuits, and the Accredo class action will continue to work through the courts, likely for years. Cancer patients and the health plans that cover them should watch for class certification decisions in these cases, which will determine whether the lawsuits proceed as broad class actions or are narrowed in scope. In the meantime, the FTC settlement has established a regulatory baseline that other PBMs — CVS Caremark, OptumRx — will likely be measured against. The era of formulary construction driven primarily by rebate revenue rather than patient cost may be ending, but the transition will be slow, and cancer patients navigating the current system need to advocate actively for their coverage in the interim.
Frequently Asked Questions
Is there a specific class action lawsuit about Express Scripts forcing non-preferred cancer drugs on patients?
There is no single lawsuit with that exact framing. However, the BLB&G racketeering class action filed in February 2026 alleges that Express Scripts sold formulary placement to manufacturers and excluded lower-cost drugs, which directly affected cancer treatment coverage. The Accredo class action addresses failures in delivering specialty cancer medications.
How much could the FTC settlement save cancer patients on out-of-pocket drug costs?
The FTC estimates the settlement will reduce patients’ out-of-pocket drug costs by up to $7 billion over 10 years across all drug categories. The savings for individual cancer patients will depend on their specific medications and plan structures. The key reform is that co-pays must be based on net cost rather than inflated list prices, which could substantially reduce what cancer patients pay at the pharmacy counter.
When do the Express Scripts formulary reforms take effect?
The FTC settlement requires Express Scripts to implement all changes no later than January 1, 2028. Until then, existing formulary structures remain largely in place, and patients must use exception requests and appeals to challenge non-preferred drug placements.
Can I join the class action against Express Scripts as an individual cancer patient?
The BLB&G racketeering lawsuit was filed on behalf of a health plan (Plumbers’ Welfare Fund, Local 130 U.A.), not individual patients. If the case achieves class certification, other health plans may be included. Individual patients are more likely to benefit from the FTC settlement’s structural reforms or from filing complaints with their state attorney general.
What should I do if Accredo delays my cancer medication?
Document every interaction, including dates, times, and representative names. Contact your oncologist immediately to arrange an emergency supply through a local specialty pharmacy if possible. File a complaint with your state’s board of pharmacy and your state attorney general’s office. If you experience medical harm from a delayed cancer medication, consult with a patient rights attorney about your individual legal options.
Was Revlimid removed from Express Scripts’ formulary?
Express Scripts excluded Revlimid (lenalidomide) for new patient starts effective January 1, 2026, with existing patients transitioned off by April 1, 2026. Patients on Revlimid for multiple myeloma should work with their oncologists to file a formulary exception request or discuss alternative treatment options.