Cost Sharing? Or Cost Shifting in Disguise…
Despite numerous existing policies and regulations in place, certain groups continue to operate as if they are untouchable… Pharmacy Benefit Managers (PBMs) and their associated dispensing pharmacies (CVS/Caremark, Evernorth/Cigna/Express Scripts, Humana, OptumRX, Prime Therapeutics to name a few) have been documented in multiple settlements, judgements, and allegations that have accounted for billions of dollars in fees and recouped amounts. Whether it is fraudulent claims cases, violating state regulations requiring PBM’s to reimburse pharmacies at their purchase price or higher, the PBM’s charging more to insurer plans or employers than what was paid out for the products or service(s), steering patients to affiliate-owned pharmacies instead of allowing for patient choice, lack of transparency or accurate reporting to various parties, or even simply violating antitrust and monopoly legislation that has existed for decades, these PBM’s have quite the track record of operating as if they are above the law…
Most recently, CVS/Caremark insurance company and affiliates have been in the news for multiple concerns, to the tune of over $1.25 billion to date in 2025… The largest chunk of this, however, includes one specific affiliate known as Omnicare who was indicted to pay nearly $949 million for violations to the False Claims Act, finding CVS jointly liable for portions of these claims. However, despite the judgement issued by the court in July 2025, Omnicare filed for Chapter 11 Bankruptcy in September, halting all collection attempts on that judgement, of which $406-plus million was for damages that affected parties are no longer able to receive until finalization of the bankruptcy case. However, they were able to obtain an additional $110 million in loans to continue operating through the bankruptcy case, further adding to their growing debt load and potentially reducing collection abilities later down the road… As an unsecured claim in the bankruptcy process, this debt could be reviewed and reduced due to the much lower asset value than the judgement balance. This means, CVS could walk away from this not owing for the court-apportioned judgement value and keep their cushion since it is only an affiliate…
This pattern is continuing to become a grave concern, proven by the growing number and value of claims against PBM’s in this country. In the years 2020 & 2021, less than $5 million in fees was publicly announced in settlements or judgements against the PBM’s. In 2022, however, the trend began to change as $23 million was reported, which grew exponentially to $173 million in 2023. The largest portion of these fees are attributed to false claims of one sort or another. Fewer claims were found in 2024 with $20 million, with 2025 to date already exponentially higher value of over $1.27 billion in claims and penalties to various of the top PBM’s. These continued findings for fraudulent claims, violating trust policies, continuing to force patients into their owned affiliates instead of allowing for choice, and misreporting or inappropriate reporting that leads to courts believing inappropriate behavior has occured are proof that these PBM’s are ignoring rules for their own financial gain, hoping not to get caught.
These types of practices must be stopped: your community’s retail pharmacy cannot survive with these types of practices continuing to pull from their pockets, most of which are already running empty… Help today by completing the petition to the Federal Trade Commission regarding the unfair and illegal practices of PBM’s across this country. Without everybody working together toward this, raising awareness and bringing to light these practices, these practices will continue in the shadows, costing Americans billions in excess healthcare costs.