The U.S. Court of Appeals for the Sixth Circuit issued a decision Monday in a closely watched case brought by Ohio Attorney General Dave Yost against five major pharmacy benefit managers, including Express Scripts Inc., Cigna Group, Evernorth Health Inc., Prime Therapeutics LLC, and Ascent Health Services LLC.
The case, *State of Ohio, ex rel. Dave Yost v. Ascent Health Services, LLC* (6th Cir. 2026), was argued before a three-judge panel consisting of Chief Judge Jeffrey Sutton and Circuit Judges Danny Boggs and Amul Thapar on Dec. 11, 2025. The court's decision, filed Jan. 27, 2026, addresses Ohio's challenge to the business practices of these pharmaceutical middlemen.
Pharmacy benefit managers serve as intermediaries between health insurers, drug manufacturers, and pharmacies, managing prescription drug benefits for millions of Americans. These companies negotiate drug prices, determine which medications are covered by insurance plans, and process claims for prescription drugs.
The lawsuit originated in the U.S. District Court for the Southern District of Ohio at Columbus, where District Judge Michael H. Watson presided over the initial proceedings. The case was filed under docket number 2:23-cv-01450 in 2023, indicating Ohio's legal challenge began that year.
Ohio's legal team was led by Michael J. Hendershot from the Office of the Ohio Attorney General, along with T. Elliot Gaiser, Jennifer L. Pratt, and Sarah Mader, all from the same office. This representation reflects the state's commitment to pursuing the case through the appellate level.
The defendants mounted a vigorous defense, assembling a team of experienced attorneys from multiple prominent law firms. Daniel J. Howley of Rule Garza Howley LLP in Washington, D.C., argued the case for the appellants, supported by a substantial legal team including Charles F. Rule, Emily M. Renzelli, Benjamin Z. Bergmann, and Erica N. Baum from the same firm.
Additional counsel for the pharmacy benefit managers included Jaime Stilson from Dorsey & Whitney LLP in Minneapolis, Minnesota, and attorneys from Ohio-based firms including Matthew L. Jalandoni and W. Benjamin Reese from Flannery Georgalis LLC in Columbus, and David J. Butler and Jeanne M. Cors from Taft Stettinius & Hollister LLP, with offices in Columbus and Cincinnati respectively.
The case is notable for receiving a "recommended for publication" designation from the Sixth Circuit, pursuant to the court's Internal Operating Procedure 32.1(b). This designation suggests the court views the decision as having precedential value and broad significance for future cases involving similar legal issues.
The Sixth Circuit's jurisdiction covers Ohio, Michigan, Kentucky, and Tennessee, meaning the decision could have implications for pharmacy benefit manager operations across the region. The court's ruling may influence how states can regulate or challenge the practices of these powerful healthcare intermediaries.
The involvement of major pharmacy benefit managers as defendants underscores the significance of the case. Express Scripts, one of the largest PBMs in the United States, manages prescription benefits for tens of millions of Americans. Cigna Group and its subsidiary Evernorth Health represent another major player in the pharmacy benefit management industry.
Prime Therapeutics, which serves as the pharmacy benefit manager for Blue Cross Blue Shield plans in multiple states, was also named as a defendant. Ascent Health Services rounds out the group of companies challenged by Ohio's lawsuit.
The case reflects broader scrutiny of pharmacy benefit managers by state and federal regulators. These companies have faced criticism over their pricing practices, rebate structures, and potential conflicts of interest in their roles as intermediaries in the pharmaceutical supply chain.
While the specific details of Ohio's claims and the court's reasoning remain to be analyzed from the full opinion, the case represents part of a growing trend of state attorneys general taking action against pharmacy benefit managers. States have increasingly questioned whether these companies' practices drive up prescription drug costs for consumers and create anticompetitive effects in pharmaceutical markets.
The decision comes at a time of heightened focus on prescription drug pricing and the role of various intermediaries in the healthcare system. Federal regulators, including the Federal Trade Commission, have also increased their scrutiny of pharmacy benefit manager practices in recent years.
The case's progression from district court to the appellate level demonstrates the substantial legal and financial stakes involved for both Ohio and the defendant companies. The comprehensive legal representation on both sides reflects the importance of the issues at stake and the potential precedential impact of the court's decision.
The Sixth Circuit's decision will likely be closely examined by other state attorneys general, healthcare industry participants, and legal practitioners specializing in healthcare law and antitrust matters. The ruling may influence future litigation strategies and regulatory approaches regarding pharmacy benefit manager oversight and state enforcement actions.