The PBM Industry Is Now Fighting a War on Two Fronts

For years, the PBM industry's primary fight was with community pharmacies.

Independent pharmacies have pushed back against below-cost reimbursement, MAC pricing, clawbacks, restrictive networks and patient steering toward PBM-owned pharmacies.

That fight isn't going away.

What has changed is who else is now in the fight.

State Attorneys General, state legislatures, the FTC and private plaintiffs are going after PBM practices through lawsuits, investigations and new laws. At the same time, PBMs are suing states to stop some of those laws from taking effect.

The industry is now having to defend itself in a lot of different places at the same time.

There is a lesson from World War II that applies here.

Germany ultimately found itself fighting major forces in both the East and the West. The problem wasn't simply winning individual battles. Fighting on multiple fronts stretched resources and made it much harder to contain the conflict.

The comparison isn't perfect, but the lesson is:

Fighting on two fronts is very different from fighting on one.

Look at What Is Happening in the Courts

The number of significant PBM cases is growing, but the bigger issue may be what these cases can uncover.

In 2025, Michigan sued Express Scripts and Prime Therapeutics over their 2019 collaboration, alleging the arrangement suppressed pharmacy reimbursement and contributed to pharmacy deserts. Rhode Island also pursued the major PBMs over their business practices. Arkansas became another battleground over PBM ownership restrictions.

In 2026, the list has continued to grow.

Florida sued Prime Therapeutics and Express Scripts over the same 2019 reimbursement arrangement, alleging an agreement that ultimately reduced reimbursement across large portions of branded and generic drugs. Louisiana followed days later with its own case involving Express Scripts and Ascent Health Services.

Iowa and Missouri have filed cases involving PBMs and insulin manufacturers. The FTC has taken action against the largest PBMs, including settlements involving Express Scripts and Caremark. And a coalition representing nearly 5,000 independent pharmacies has filed its own federal antitrust case against Express Scripts and Prime.

Then there is the fight over ownership and vertical integration.

Tennessee passed the FAIR Rx Act in 2026, and CVS, Express Scripts and PCMA have challenged the law in court. That follows the fight in Arkansas over a similar ownership restriction.

These aren't all the same case. They involve different states, different plaintiffs and different legal theories.

But they are increasingly asking similar questions about how the PBM business operates.

Discovery Could Change the Conversation

This is where the lawsuits become particularly important.

A lawsuit doesn't just determine who wins or loses a particular dispute.

Once cases move into discovery, plaintiffs can start asking for the documents and information behind the practices being challenged.

How are reimbursement rates actually determined?

How are MAC prices established and changed?

Where do manufacturer payments go?

How do PBMs and their affiliated companies interact?

What do internal communications say about reimbursement and pharmacy economics?

What information is being used to make these decisions?

Those are questions that are difficult to answer from the outside.

Discovery has the potential to start peeling back those layers.

One case may uncover one practice. Several cases involving similar practices could begin to establish a much larger pattern.

And evidence uncovered in one case can create questions for regulators, legislators and plaintiffs in other states.

That's why the growth in litigation matters beyond the individual lawsuits.

The Pharmacies Are on the Front Lines

This is where pharmacies have a role that shouldn't be underestimated.

During World War II, Rosie the Riveter became a symbol of the millions of Americans working behind the scenes to supply the people fighting on the front lines.

There is a similar role for pharmacies in this fight.

Pharmacies are on the front lines, and they are generating the evidence.

Every day, a pharmacy sees a reimbursement below acquisition cost. It sees a MAC price that doesn't make sense. It files an appeal. The PBM responds. The pharmacy either gets paid or it doesn't.

Most of that information historically stays inside the pharmacy.

But what happens when those appeals are captured consistently across thousands of pharmacies?

The individual appeal becomes a data point.

Thousands of appeals become a pattern.

And patterns are much harder to dismiss.

Where Pharmacy Marketplace Fits

This is where Pharmacy Marketplace has an opportunity to play a bigger role.

The goal isn't for Pharmacy Marketplace to decide whether a PBM broke the law. That's the job of regulators and courts.

The opportunity is to help pharmacies document what is happening and create a reliable record.

The acquisition cost.

The reimbursement.

The NDC.

The PBM.

The MAC price.

The appeal.

The PBM response.

The outcome.

That information can be valuable to the pharmacy because it can help recover money.

But it can also become part of something much bigger.

Think of the pharmacies as the people on the ground and Pharmacy Marketplace as part of the infrastructure supporting them.

The pharmacies are seeing the problems firsthand. The appeals document those problems. Pharmacy Marketplace can organize that information so that it doesn't disappear into thousands of individual pharmacy files.

And as more lawsuits move into discovery, having that evidence already organized becomes increasingly important.

The Two Fronts Are Starting to Connect

The pharmacy fight is producing evidence.

The lawsuits are creating opportunities to get behind the business practices.

Discovery can reveal information that has been difficult to see from the outside.

And the information coming from pharmacies can help show what those practices actually mean at the ground level.

That's what makes the current environment different.

The PBM industry isn't simply fighting another round of reimbursement disputes or another round of state legislation.

It's facing pressure from pharmacies, Attorneys General, state legislatures, federal regulators and private plaintiffs — often at the same time.

And the people who may ultimately have some of the most important evidence aren't sitting in corporate offices.

They're behind the counter at independent pharmacies.

The pharmacies are doing the work of documenting what happens every day.

Pharmacy Marketplace can help make sure that evidence is captured, organized and doesn't get lost.

Because if this really is a two-front war, the side that can document what is happening on the ground may ultimately have an important advantage.