UCSF Researchers Call for Limits on Drug Rebates After Tracing Undisclosed Ties Between PBMs and Opioid Makers

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VALERY HACHE | AFP via Getty Images Share on Twitter Share on Facebook Share on Pocket Pharmacy benefit managers, the companies that manage prescription drug benefits for insurers and employers, had undisclosed financial relationships with opioid manufacturers that may have worsened the opioid crisis, according to a study published in JAMA Health Forum on Oct. 9. The University of California, San Francisco researchers recommend regulatory limits on those relationships, including eliminating rebates.

The study arrives as cities and states press lawsuits accusing the largest PBMs of helping opioids flow freely. It adds peer-reviewed research to a debate that has largely played out in court filings and news investigations.

For patients, the issue is not abstract. PBMs shape what a prescription costs at the pharmacy counter, which drugs need prior approval, and how many pills a plan allows. The researchers argue that when payments from drugmakers influence those decisions, public health can suffer.

Rebates are payments a drugmaker gives a PBM after a drug is covered and dispensed, and they are usually confidential. In the opioid context, critics say, a larger rebate could make a PBM less likely to add limits such as prior authorization or caps on pill counts, the very safeguards meant to curb overprescribing.

The study, titled “Pharmacy Benefit Manager Involvement in the US Opioid Crisis,” lists Dorie E. Apollonio, PhD, MPP, of UCSF’s Center for Tobacco Control Research and Education as corresponding author. JAMA Health Forum labeled it an editor’s pick.

According to the JAMA Network media release, the authors concluded that regulatory restrictions on these relationships, including the elimination of rebates, “could increase transparency” and reduce public health risks from misuse of addictive medications.

There are limits to what the public summary shows. It does not detail the documents analyzed, the years covered, the specific companies involved, or the dollar amounts, and the full methods were not available for independent review. The study describes relationships that may have worsened the crisis, which is not proof of how much any one payment changed prescribing and is not a legal finding of liability.

The research echoes claims already in court. A New York Times investigation published in December 2024 reported that Express Scripts, CVS Caremark and Optum Rx made deals with opioid makers in exchange for large rebates, according to Becker’s Hospital Review. The Times reported that Purdue Pharma paid PBMs about $400 million a year from 2003 to 2012 to head off limits such as pill caps.

Local governments have since sued. In October 2025, the City of Philadelphia filed a lawsuit against all three companies. The city alleges they gave opioids favorable formulary placement in exchange for rebates and fees for at least two decades. Kentucky, Mississippi, Arkansas, and other states have filed similar suits against Express Scripts, Optum, or both.

“Even while knowing the dangers of opioid overuse, these companies chose profit over people,” Philadelphia Mayor Cherelle L. Parker said when the suit was filed.

Federal action has been narrower. In 2024, Optum Rx agreed to pay $20 million to resolve Justice Department allegations that it filled certain opioid prescriptions despite unresolved red flags, with no determination of liability. In December 2024, four House members, led by Reps. Deborah Ross and Buddy Carter, asked the Justice Department to investigate PBMs and their role in the crisis.

The companies deny wrongdoing. Responding to a Boston lawsuit in 2024, Optum said it “did not cause the opioid crisis or make it worse,” and that it would defend itself in the litigation, WBUR reported.

Express Scripts said it has long worked to combat opioid overuse and abuse and would contest what it called baseless allegations in court, according to an Associated Press report on Kentucky’s lawsuit. According to the Justice Department’s settlement announcement, Optum Rx adopted stricter opioid dispensing protocols starting in 2017.

PBMs also argue that rebates lower costs for health plans and employers and that those savings are passed on through lower premiums. That is the core of the policy fight. Critics say rebates reward drugmakers for high list prices and steer coverage toward the products that pay the most. Supporters say negotiated discounts would be lost without them. The UCSF authors favor tighter limits, at least where addictive drugs are involved.

None of the lawsuits have produced a verdict holding a PBM liable for the opioid crisis. Some cases have been narrowed, and on Oct. 2 a federal appeals court blocked hundreds of late-filed claims against PBMs in the national opioid litigation. Other cases continue in federal and state courts.

Patients prescribed opioids for pain should not stop or change their medication because of this study. Stopping suddenly can cause withdrawal and other risks, so talk with the prescribing clinician first.

Families can still take practical steps. Ask the prescriber how long the medication is needed, what the lowest effective dose is, and whether non-opioid options might work. Store opioids securely and dispose of unused pills at pharmacy take-back sites. Keep the overdose-reversal medicine naloxone at home if anyone in the household uses opioids.

If an insurer or PBM denies a medication or limits a prescription, patients can ask the plan for the reason in writing and request an appeal with help from their clinician. Employers that offer health plans can ask their PBM to disclose rebate arrangements.

MedicalDaily will report on rulings in the Philadelphia case and other suits, and on any federal action on rebate transparency.

What did the UCSF study find? It concluded that PBMs and opioid manufacturers had undisclosed financial relationships that may have worsened the opioid crisis. The authors recommend limits, including eliminating rebates.

What is a pharmacy benefit manager? A PBM manages prescription drug benefits for insurers and employers. It negotiates with drugmakers, sets drug lists, and applies rules like prior authorization and quantity limits.

Does the study prove PBMs caused the opioid crisis? No. It describes financial ties and their possible effects. Courts have not found any PBM liable for the crisis.

Which PBMs face opioid lawsuits? Philadelphia has sued Express Scripts, CVS Caremark, and Optum Rx, and several states have sued Express Scripts, Optum, or both. The companies deny the allegations.

Should I stop taking a prescribed opioid? No. Do not stop or change your medication without talking to your clinician, since stopping suddenly can be risky.

What can I do if my plan denies a medication? Ask your plan for the reason in writing and file an appeal with help from your clinician.