Pharmacy benefit managers (PBMs) manage prescription coverage for health plans and big employers. They decide which medicines are covered and at what price, negotiate discounts with drug makers, and set prices for pharmacies. PBMs arose in the late 1960s and early 1970s as employer-sponsored drug coverage and public programs expanded, then grew rapidly in the 1990s. Their core rationale was to centralize purchasing and administrative costs across sprawling drug markets.
As PBMs have grown in both size and influence, they have attracted scrutiny from regulators, Congressional investigators, and consumer groups for their pricing and reimbursement practices. At the same time, regulators have also started to pay more attention to the dispensing practices of pharmacies, which some view to have contributed to the opioid epidemic. In recent years, the size, pricing power, and ability of PBMs and pharmacies to control public access to drugs has led regulatory agencies, including the United States Department of Justice (DOJ), to view them less as functionary players in the healthcare ecosystem and more as influential gatekeepers.
In 2025, these patterns have become even more pronounced as pharmacies and PBMs have found themselves at the center of a series of headlines, underscoring a broader trend that placed them squarely among the DOJ’s primary False Claims Act (FCA) enforcement targets.
In April, the DOJ announced a $350 million settlement with Walgreens for illegally filling...
An appellate court has shut the door on reviewing the constitutionality of the qui tam provisions of the False Claims Act (FCA), although two other appellate courts are reviewing this issue, with ...