Twelve independent pharmacies in Arkansas are suing Express Scripts alleging the pharmacy benefit manager repeatedly underpaid them on tends of thousands of drug prescriptions, in violation of state law.
In a lawsuit (PDF), filed in the Circuit Court of St. Louis County, Missouri., the pharmacies seek compensatory and statutory damages, along with court orders aimed at future compliance, reprocessing affected claims, and creating a workable appeals process. The complaint seeks hundreds of millions of dollars in statutory damages, according to attorneys representing the pharmacies.
Under Arkansas law, a PBM may not reimburse an Arkansas pharmacy less than the pharmacy’s cost of acquiring the drug itself—generally measured by the National Average Drug Acquisition Cost, the federal government’s drug-specific, weekly-updated benchmark of what pharmacies actually pay to acquire each medicine.Â
"NADAC is a floor beneath the ingredient cost. It is a minimum payment, not a suggestion, and not an after-the-fact appeal target," the pharmacies wrote in the lawsuit.
The pharmacies claim Express Scripts underpaid them on prescriptions despite having the data and systems needed to comply with the law in real time. They argue that pharmacies are forced to absorb losses because challenging each underpayment through appeals is burdensome and often costs more than the amount at issue.
Express Scripts is a PBM within Cigna's Evernorth unit.
According to the complaint, from August 2025 through March 2026, Express Scripts reimbursed the pharmacies below the statutory floor "not less than tens of thousands of times—across hundreds of drugs, month after month, through Express Scripts’ centralized pricing and adjudication systems," the plaintiffs wrote in the lawsuit.
The underpayments put pressure on pharmacy finances and patient access, the pharmacies argue.
The pharmacies also allege that Express Scripts has all the data required to honor that reimbursement floor at the moment it prices each claim: the drug code, quantity and fill date; the current NADAC files published by the Centers for Medicare & Medicaid Services (CMS) and centralized adjudication systems that already apply plan-specific pricing rules, formularies, and edits in real time.
"Express Scripts’ failure to comply with Arkansas law is not a technological challenge; it is a business decision," the pharmacies wrote.
Arkansas regulators have taken steps to address reimbursement issues to pharmacies. Beginning in 2021, the Arkansas Insurance Department issued a series of bulletins directing PBMs to build NADAC-minimum claim practices, honor invoice-based and bulk appeals from pharmacies, and to stop invoking contract labels or national systems as excuses for below-floor payment, according to the complaint.
By April 2024, AID was processing roughly 1,000 to 1,500 below-NADAC claims every month and emphasizing that even small shortfalls violate the law.Â
In August 2024, Governor Sarah Huckabee Sanders and the Arkansas Insurance Department announced notices of penalties in the amount of nearly $1.5 million against Caremark, Express Scripts, MedImpact and Magellan as a result of paying Arkansas pharmacies below the NADAC, in violation of state law.
A 2025 state law gave pharmacies the right to sue and pursue statutory and other remedies for certain reimbursement violations.
The plaintiffs argue that independent pharmacies operate on working capital as they must continuously buy inventory before reimbursement arrives. "Repeated shortfalls therefore reduce both current marginÂ
and the capacity to purchase the next patient’s medicine. Below-cost payment leads a pharmacy to cut inventory, hours, delivery, staffing, or patient capacity—degradation that occurs gradually, before it ever appears in closure data—or ultimately to sell or close altogether," the pharmacies wrote in the lawsuit.
The plaintiffs also argue that fighting underpayments places significant burden on the pharmacies. "Each complaint required the pharmacy to identify the claim, assemble invoices, submit and monitor an appeal, and reconcile the result. For small-dollar shortfalls, that labor can exceed the amount withheld, making a nominal appeal practically useless," according to the complaint.