Twelve independent pharmacies in Arkansas have initiated legal action against Express Scripts, claiming the pharmacy benefit manager has underpaid them for thousands of drug prescriptions in violation of state law. The lawsuit, filed in the Circuit Court of St. Louis County, Missouri, seeks not only compensatory and statutory damages, but also court mandates to ensure future compliance, reprocessing of affected claims, and the establishment of an effective appeals process.
The pharmacies aim for hundreds of millions of dollars in statutory damages based on assertions that Express Scripts compromised their financial health by failing to pay the mandated minimum for prescription drugs. According to Arkansas law, a pharmacy benefit manager cannot reimburse in excess of the National Average Drug Acquisition Cost (NADAC) which serves as a benchmark for what pharmacies pay to acquire medications.
The pharmacies emphasize that "NADAC is a floor beneath the ingredient cost. It is a minimum payment, not a suggestion..." They argue that Express Scripts had the data and systems necessary to comply with this law in real-time yet repeatedly underpaid them on prescriptions. The complaint notes that from August 2025 to March 2026, there were instances of underpayment not less than tens of thousands of times across hundreds of drug claims.
The financial pressures resulting from these alleged underpayments are significant, they assert. The pharmacies argue that challenging each underpayment through formal appeals can be cumbersome and economically unviable, often costing more than the shortfall itself.
Express Scripts, part of Cigna's Evernorth unit, allegedly compromised the pharmacies' finances, impacting patient access to necessary medications in the process. The pharmacies claim that a decision on pricing from Express Scripts contributes to these issues, as they contend that it is a business decision rather than a technological oversight.
The complaint also states that Express Scripts has all the relevant data at hand to adhere to reimbursement requirements, such as drug codes, quantity, fill dates, and updated NADAC files from the Centers for Medicare & Medicaid Services (CMS).
In recent years, Arkansas regulators have been proactive in addressing reimbursement issues specific to pharmacies. Since 2021, the Arkansas Insurance Department has issued directives for PBMs to adopt NADAC-minimum claim practices, ensuring that invoice and bulk appeals from pharmacies are honored, and ceasing the use of contract language as an excuse for below-floor payments.
In April 2024, the department began processing 1,000 to 1,500 claims that fell below the NADAC benchmark each month, underscoring the severity of the issue. Notices of penalties totaling nearly $1.5 million have also been levied against several PBMs, including Express Scripts, for their failure to comply with reimbursement laws.
A new law established in 2025 grants pharmacies the right to pursue legal remedies for certain reimbursement violations, providing an additional tool for these independent pharmacies in their legal battle. They argue that independent pharmacies generally operate on thin margins, requiring constant purchase of drugs before receiving reimbursement. These underpayment issues threaten their ability to maintain inventory, staff, and ultimately remain operational.
The complaint articulated concerns that excessive labor associated with filing appeals not only strains resources but also diverts attention from patient care, indicating that the cumulative effect of these shortfalls can lead to closures or reductions in pharmacy services.
In their closing arguments, the pharmacies note that much of the labor involved in addressing underpayments for small amounts can often exceed the value of the amount in dispute, rendering appeals nearly futile.
As this lawsuit progresses, it reflects broader concerns over the accountability of pharmacy benefit managers and their impact on independent pharmacies and patient care in the state of Arkansas.
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