Florida Attorney General James Uthmeier filed a complaint in the Eleventh Judicial Circuit on September 22 against nine entities in the insulin market. Three are manufacturers: Eli Lilly, Novo Nordisk and Sanofi, which together supply more than 90 percent of the world's insulin. Three are pharmacy benefit managers: CVS Caremark, Express Scripts and OptumRx, which process roughly 80 percent of American prescriptions. The last three are the least familiar names in the group and the most interesting ones in the pleading. Zinc, Ascent and Emisar are rebate aggregators, captive affiliates that do the rebate contracting for the PBMs above them.
That third layer is where the arithmetic of insulin pricing gets done, and it is the layer most consumers, and many plan sponsors, have never contracted with.
Nine defendants across three layers
The complaint brings two counts under the Florida Deceptive and Unfair Trade Practices Act and one under the Florida Antitrust Act. It asks for a permanent injunction, restitution, disgorgement, damages and civil penalties. It covers insulin and related diabetes products, and it reaches GLP-1 and combination drugs as well, naming Ozempic, Trulicity, Victoza and Soliqua. Uthmeier announced the filing at a news conference in Tampa, flanked by a state representative, a former state representative and independent pharmacists, and said additional suits over prescription drug prices could follow.
The state's factual core is a two-price market. Insulin carries a published list price and a lower net price after the rebates and discounts that flow back to the PBM. Patients who are uninsured, still inside a deductible, or on percentage coinsurance are billed against the list price, which is the number that has climbed. The complaint cites testimony from a Lilly executive that of every $280 vial of Humalog, about $210, roughly three quarters, returns to the PBMs as rebates and discounts in exchange for formulary position. The state notes that about 2.3 million Florida adults, one in ten, have diagnosed diabetes.
None of the companies had responded to the suit when it was first reported. The allegations are unproven.
How the list price became the number that matters
The two-price structure did not appear by accident, and the federal complaint against the PBMs lays out the sequence the state is now borrowing. According to the FTC's case, the PBMs began building restrictive formularies and demanding progressively larger rebates and fees from insulin makers in exchange for placement on them. Because a rebate is calculated as a percentage of the published list price, a higher list price raises the rebate pool that the manufacturer and the PBM divide. Both sides of the negotiation benefit as the sticker price climbs. The patient who pays that sticker price is on the other side of the table, or outside the room entirely.
The FTC's numbers trace the result. Humalog listed at $21 a vial in 1999 and more than $274 by 2017, and American spending on insulin roughly tripled between 2012 and 2022, reaching $22.3 billion. The sharper allegation is what happened when a cheaper option appeared. When lower list price versions of insulin came to market, including authorized generics priced at roughly half the brand, the commission alleged that the PBMs excluded them in favor of higher-priced versions that carried larger rebates. A product that was cheaper for a cash-paying patient at the pharmacy counter was kept off the formulary, the commission alleged, because the cheaper product generated less money upstream.
That is the mechanism Florida has to make concrete. The state does not need to prove that nine companies met in a room and agreed to raise prices. It needs to prove that the arrangements they signed made the higher list price the rational choice for every party that negotiated one, while the party that could not negotiate one paid it.
The aggregator is where the fee trail bends
Rebate aggregators, sometimes called rebate group purchasing organizations, exist to negotiate and administer the contracts between drugmakers and PBMs. They are staffed by people who held the same roles inside the PBMs, and they perform the commercial rebate contracting function the PBMs once handled themselves. Their rise is recent enough that the Federal Trade Commission's 2024 administrative complaint against Caremark, Express Scripts and OptumRx and their respective aggregators was described in later litigation as the first public accounting of what the entities do.
The structural point is what happens to the money as it passes through. Health plans contract with the PBM. They do not contract with the aggregator, and their agreements frequently do not name it. Every dollar the aggregator receives from a manufacturer does not have to be reported to the plan as a rebate, because a portion of it can be classified as a fee for administering the rebate program. Litigation filed by other states has described the pattern in illustrative terms: an aggregator collects a sum from drugmakers, passes most of it to the PBM to flow through to the client as rebates, and retains the remainder as fees that the client has no contractual right to see. That characterization comes from plaintiffs who are suing over the practice, and the entities involved dispute the framing. It is also the reason a plan can be told it receives 100 percent of rebates and still be paying for access it was never shown an invoice for.
For a state attorney general, that matters for a simple reason. If the fee sits with the aggregator, a judgment has to reach the aggregator to move it.
What the federal case already decided, and for whom
Florida's suit arrives late to a party that has been splitting for two years. The FTC filed its insulin case in September 2024 against the three PBM families and their aggregators. It has since settled with two of them. Express Scripts and its affiliates, including Ascent, signed a consent decree in February 2026 that requires pricing practices to be rewritten: no excluding lower list price versions of a drug in favor of a higher list price version that carries bigger rebates, member cost sharing tied to net cost rather than list price, and a direct-to-consumer purchase route. Caremark and Zinc followed with a settlement of their own in July 2026.
OptumRx and Emisar are the respondents still litigating, and the remedies already agreed apply to conduct with implementation deadlines that stretch into January 2027.
That timeline produces an awkward overlap for the Florida complaint. It names all three PBM families and all three aggregators, including the two pairs that have already accepted federal conduct remedies, alongside manufacturers the FTC has never charged. The commission's then-deputy competition director said in 2024 that the investigation had also uncovered the manufacturers' role and warned of possible future enforcement. Florida has now filed the version that names everyone at once.
What a state court can order that a consent decree does not
The distinction that will decide whether this case matters is the remedy, not the liability theory.
The FTC's insulin settlements are conduct decrees. They change how the defendants price, what they may exclude from a formulary, and how patient cost sharing is benchmarked. They do not write checks to patients. The commission's authority to obtain equitable monetary relief was narrowed by the Supreme Court in 2021, which pushed its consumer-protection remedies toward rules and cease-and-desist orders rather than restitution.
Florida's statutes point the other way. The Deceptive and Unfair Trade Practices Act lets the attorney general seek actual damages on behalf of consumers who were injured, and it carries civil penalties of up to $10,000 for each willful violation, rising to $15,000 where the victim is a senior citizen. Restitution orders in favor of protected groups take priority over civil penalties. An antitrust count adds the possibility of damages and disgorgement on top of that.
This is the practical difference between a federal conduct case and a state consumer case. One rewrites a contract template. The other sends money to the people who paid the inflated price, and in Florida's case, to a state treasury that collects penalties. Neither is guaranteed. Both are sought here.
What the state has to prove, and against whom
The hardest element in any insulin case is causation at the level of the individual patient. A state has to connect a pricing architecture that operated across the entire market to a specific Floridian who paid a specific inflated price, and it has to do so against defendants who will argue that the prices were published, that the rebates were disclosed to the plans that negotiated them, and that formularies were designed to hold down net costs for the employers and unions that sponsor coverage.
There is also a division of labor problem inside the complaint. A manufacturer defending itself will point at the PBMs, which is precisely the argument the FTC made when it named both sides. A PBM that has already agreed to a federal conduct decree will point at that decree, and at the fact that it is now implementing it. The aggregators, for their part, will argue that they negotiate on behalf of plans rather than against them and that fees for rebate administration are a disclosed commercial arrangement with their PBM parents.
Florida is building a record in parallel. The attorney general filed a separate suit on August 27 against Prime Therapeutics and Express Scripts over pharmacy reimbursement, and similar cases are pending in other states and in a federal multidistrict litigation that consolidated insulin pricing claims in New Jersey. Whatever this complaint produces, it will not be the last word, and the state's own announcement framed it as the opening of a broader effort.
What the aggregators add is the part of the mechanism that federal conduct decrees are least able to reach. A decree tells a PBM how to price. It does not automatically follow the fee to an affiliate that never signed it, and it does not return anything to the patient who paid the list price while the fee was being collected upstream. If the rebate trail was deliberately routed through entities that plans never contracted with, then the remedy has to be routed there too, and that is a claim a state consumer statute is better built to carry than a federal antitrust settlement. The case will turn on whether Florida can prove the routing was a scheme rather than a structure.
Primary sources
- Office of the Attorney General of Florida, release and complaint, Attorney General James Uthmeier Takes Legal Action Against Insulin Manufacturers and Pharmacy Benefit Managers (September 22, 2026).
- Federal Trade Commission, In the Matter of Caremark Rx, LLC; Zinc Health Services LLC; Express Scripts, Inc.; Ascent Health Services LLC; OptumRx, Inc.; Emisar Pharma Services LLC, Docket No. 9437, Matter No. 221-0114.
- Fox 13 News and News4Jax for the announcement details, the pricing testimony and the relief sought in the Florida complaint.
- Fierce Healthcare for the separate Florida action against Prime Therapeutics and Express Scripts filed August 27, 2026.
- Florida Statutes, Sections 501.207, 501.2075 and 501.2077 for the attorney general's remedies and civil penalty amounts.