GPO PAPER TRAIL: Eight States, One Pattern

From Ohio to Delaware, state attorneys general and auditors are finding the same thing. Different courts, different contracts, same playbook.

Eight state actions in three years, targeting the same three PBM-affiliated GPOs. When the same pattern shows up across states and courtrooms, it stops being a coincidence and starts being a business model. The court filings and state audits tell a consistent story. Across every action, investigators found the similar conduct:

• Classifying rebates as other fees to retain a higher percentage of payments

• Shield PBMs from transparency measures (hide profits from plan sponsors)

• Charge additional “administrative fees” for extra profits

The evidence by state:

• Ohio: Ohio ex rel. Yost v. Ascent Health Services, LLC (March 2023) (Ongoing) Ohio AG Yost alleged Express Scripts, Prime Therapeutics, & Humana engaged in price fixing, using Prime Therapeutics’ stake in Ascent to eliminate competition with Express Scripts by aligning prices and using PBM GPO contracts to increase out of pocket costs.

• Hawaii: Hawaii v. CaremarkPCS Health; Express Scripts Inc.; and OptumRx Inc. (October 2023) (Ongoing)

  The State of Hawaii alleges 3 largest PBMs use GPOs to recategorize income streams and avoid rebate passthrough obligations.

• Vermont: State of Vermont v. Evernorth Health, Inc. et al (July 2024) (Ongoing)

  The State of Vermont filed suit against Cigna and CVS Health regarding how PBM-affiliated GPOs assess admin fees, prescription data service fees, data portal fees, enterprise fees, and others based on % of drug list prices.

• Illinois: CaremarkPCS Health, L.L.C., Zinc Health Services, LLC v. Kwame Raoul, as Attorney General of the State of Illinois (March 2025) (Settled)

  Illinois sued CVS and Zinc alleging CVS used Zinc to collect millions in rebates that should have gone to the state, which CVS countersued to block release of contracts and then settled with $45 million payment from Zinc to the state.

• Rhode Island: State of Rhode Island v. CaremarkPCS Health (May 2025) (Ongoing)

  The state sued Big 3 PBMs (& their GPOs) alleging used them to collect rebates and recategorize income streams, allowing avoidance of pass-through requirements.

• Illinois (audit): Illinois Department of Insurance Market Conduct Examination: Caremark LLC, Caremark PCS Health LLC. (August 2025) (Audit Completed)

  GPO’s primary goal is maximizing rebate amounts: receiving up to 5% of WAC of products dispensed, and refused to allow auditors to review manufacturers contracts.

• Virginia: Commonwealth of Virginia Ex Rel. v. Evernorth Health, Inc. et al (December 2025) (Consolidated in Insulin Pricing Litigation)

  State of Virginia sued the Big 3 Insurers (and subsequent PBMs & GPOs) alleging GPOs rename, obfuscate, and fail to pass through manufacturer rebates (substantial source of PBM profits).

• Delaware: State of Delaware et al v. Eli Lilly and Company et al (January 2026) (Consolidated in Insulin Pricing Litigation)

  The state of Delaware alleged Big 3 PBMs used GPOs to increase enterprise-wide profits and drive high drug prices.

• Louisiana: State of Louisiana v. Express Scripts, Inc. and Ascent Health Services, LLC (August 2026) (Ongoing)

  Louisiana AG Murrill alleged Express Scripts colluded with competitor Prime Therapeutics to align pharmacy reimbursement rates and fees while jointly expanding their bargaining power over drug manufacturers.

8 states have now filed or completed formal actions. The same three GPOs appear in nearly every one. The paper trail does not lie. Read part 1 and 2 of the GPO Paper Trail series: The Contract You Can't Read Because It's Overseas & The Audit That Found $15.8 Million. Who Kept It? to understand more about GPOs and how they function.