For physicians, the growing influence of pharmacy benefit managers is affecting how easily they can prescribe medications, how much patients pay out of pocket and how long treatment takes to begin, according to a July report from the American Medical Association.
Four PBMs now control more than two-thirds of the market that determines which drugs are covered, how much they cost and how they are reimbursed, the AMA said.
“The biggest disruption in my practice are the rampant medication prior authorization denials from the pharmacy benefit managers employed by both commercial and governmental insurance companies/entities,” Christopher Magiera, MD, gastroenterologist in Oshkosh, Wis., told Becker’s. “This negatively impacts patient care.”
Here are seven updates from PBMs in the last month:
1. Medicare premiums could rise as rival insurers acquire pharmacy benefit managers, according to a January study published in the American Economic Journal: Applied Economics. Medicare Part D insurers that continued working with competitors’ PBMs saw significant premium increases, suggesting higher costs for beneficiaries. For example, as independent Part D PBMs declined, monthly premiums rose by $22, or 42%, for enrollees in nonintegrated plans after UnitedHealth Group’s 2015 acquisition of Catamaran.
2. Express Scripts agreed to pay a $1.5 million administrative penalty and implement corrective actions following an investigation by the West Virginia Offices of the Insurance Commissioner. Between May 2024 and August 2025, the state reviewed the PBM’s compliance with state law in areas including reimbursement practices, pharmacy audits, consumer appeals and network adequacy. The review covered Express Scripts’ operations from Jan. 1, 2023, through June 1, 2024.
3. CarepathRx has joined Evernorth Health Services, a division of The Cigna Group. The acquisition was completed in 2025 as part of Evernorth’s strategy to expand support for patients with specialty conditions and the clinicians who treat them. The move follows a 2023 strategic partnership between Evernorth and CarepathRx Health System Solutions, a CarepathRx subsidiary. At the time, Evernorth also made a minority investment to expand pharmacy and infusion services for hospitals and health systems treating patients with chronic and complex conditions.
4. Louisiana Attorney General Liz Murrill reached a $45 million settlement with CVS Health and its PBM subsidiary, resolving three lawsuits over alleged regulatory and competitive misconduct. The lawsuits involved allegations tied to consumer communications about pending legislation, PBM regulatory practices and harm to Louisiana’s independent pharmacies from unfair competition. The settlement resolves all claims without any admission of liability or wrongdoing by CVS.
5. Two Connecticut cities have filed federal lawsuits against Cigna, CVS Health and UnitedHealth Group, targeting their pharmacy benefit managers over an alleged insulin pricing scheme. Along with Express Scripts, Evernorth, CVS Caremark and Optum Rx, the lawsuits from Norwalk and New Haven also name drugmakers Eli Lilly, Novo Nordisk and Sanofi, as well as group purchasing organizations. The cities, which operate self-funded health plans, said they were significantly overcharged for insulin. The complaints allege fraudulent activity and violations of federal anti-racketeering laws, as well as state and federal antitrust laws. Norwalk and New Haven are seeking monetary damages, restitution, attorney fees and injunctions to stop the alleged conduct.
6. The North Carolina Department of Justice and North Carolina Department of Insurance alerted PBMs on Feb. 17 that the state’s SCRIPT Act is now in effect and said they are prepared to enforce it. The North Carolina General Assembly passed the law in 2025. The legislation requires PBMs to allow any pharmacy to participate in their networks, permit patients to use the pharmacy of their choice, pass most negotiated drugmaker savings directly to patients, submit annual reports to the North Carolina Department of Insurance and reimburse independent pharmacies more fairly. The law also gives the Department of Insurance stronger regulatory and enforcement authority and grants the Department of Justice additional power to enforce North Carolina’s Unfair and Deceptive Trade Practices Act against PBMs.
7. AmeriHealth Caritas is exiting the PBM business and transitioning from PerformRx to Optum Rx, the insurer confirmed to Becker’s on Feb. 17. AmeriHealth Caritas said the move comes after a multiyear review of PBM options. PerformRx will end operations in its current form on Dec. 31, and the transition to Optum Rx will take effect at the start of 2027.
