TOPEKA, Kan. (AP) — As consumers worry about medication costs, states are trying to lower drug prices by reining in big companies that oversee prescription coverage for health insurers.
Some of those companies, called pharmacy benefit managers, also own pharmacies, and one of them, CVS, has spent millions of dollars fighting the regulations.
Affordability is a key issue ahead of this year’s midterm elections. Legislators in at least a dozen states passed laws this year to limit compensation to the companies, set minimum payments from the companies to pharmacists and require the companies to disclose more information to their clients, states and the public.
A Tennessee law will bar pharmacy benefit managers from operating retail pharmacies as of July 1, 2028, though CVS Health Corp. has filed a federal lawsuit to avoid having to close its 136 pharmacies there.
About 6 in 10 U.S. adults said in a poll conducted earlier this year by healthcare research nonprofit KFF that they were at least somewhat worried about being able to afford their prescriptions. About 4 in 10 said costs had led them not to take medications as prescribed within the previous year, either by taking less than the prescribed dose, using over-the-counter substitutes or not filling prescriptions.
Pharmacy benefit managers, particularly CVS and two other large companies, handle most U.S. prescriptions.
Lawmakers in at least 26 states introduced more than 120 bills this year on PBMs, according to an Associated Press search using the bill-tracking software Plural, with about a quarter of the bills clearing at least one chamber.
The companies manage pharmacy claims for health insurers and negotiate with manufacturers over drug prices and what medications will be covered. Critics concede that the size of the top companies gives them leverage that health plans wouldn't have on their own.
The benefit managers argue that they're the only player in the drug supply chain created to help push drug costs down and they claim credit for an increased used of less-expensive generic drugs, now 90% of U.S. prescriptions.
“If PBMs already didn’t exist, you’d need to invent one,” Prem Shaw, president of the CVS Health group overseeing its pharmacy and PBM operations, said in a recent interview. “Blaming PBMs for high drug prices is like blaming umbrellas for the rain.”
Drug companies, PBMs and their allies have spent at least $24 million on opposing broadcast and digital advertising since the start of 2025 to influence public opinion, according to the ad-tracking firm AdImpact. CVS spent $4 million this year on ads opposing Tennessee's new law.
CVS sued Arkansas last year after it enacted similar legislation, and a federal judge blocked its law. CVS also settled three lawsuits in which Louisiana accused it of unfair trade and deceptive practices in lobbying against legislation there last year, agreeing to pay $45 million without acknowledging wrongdoing.
The CVS lawsuit in Tennessee alleges that the company, which operates 9,000 pharmacies nationwide, is facing “naked protectionism” from lawmakers who operate independent pharmacies — including the law's main sponsor, state Sen. Bobby Harshbarger, and co-sponsor Sen. Shane Reeves.
In Knoxville, Seth White, who manages a CVS pharmacy, will have to find a new job if the Tennessee law stands, and he's also worried about hundreds of its customers having to go elsewhere for their medications.
Some 900 miles (1,400 kilometers) away in Coldwater, Kansas, Lisa Gales is on the opposite side of the debate. She and her husband operate the Main Street Pharmacy, and she said they rely heavily on sales of non-pharmacy items to offset low reimbursements from pharmacy benefit managers.
Gales calculates she lost money on 86% of the prescriptions she filled last year. A new Kansas law will require PBMs to pay a $10.50 dispensing fee per prescription. Gales called it a “great win,” even though, “It’s still way under what it’s costing us.”
A new Louisiana law imposes an $11.81 dispensing fee. Another says PBMs must operate for the benefit of their health-insurer clients and people enrolled in health plans.
Critics deride each mandatory dispensing fee as an extra “pill tax” that will drive up consumers' costs. Backers dispute that, saying the laws also limit what PBMs charge health plans for the cost of medications themselves — so that it's often well below wholesale prices.
Pharmacy benefit managers push drugmakers to give big discounts on those wholesale prices but face criticism for keeping any portion of them. Some states now require PBMs to pass along all discounts.
It all worries consumers, particularly in small towns, who fear it could become harder to get their medications if PBMs squeeze independent pharmacies on reimbursements to the point of endangering their businesses.
In southeastern Kansas, Faith Sanders, a 79-year-old retired nursing home administrator, said the pharmacy in her hometown of Cedar Vale is important because without it people would have to drive 35 miles (56 kilometers) “to go out of town to get anything.”
For her many elderly neighbors, she said, “We get to the point where it’s hard for us to get out of town.”
Meanwhile, even some PBM critics question whether states can effectively regulate them. In Tennessee, state Rep. Robert Stevens, a Nashville-area Republican, told colleagues during a debate that cracking down on PBMs “needs to be done by Congress and not by us.”
Congress did pass new PBM regulations in February. One law will prevent PBMs from keeping any rebates they’ve negotiated on drug prices for health plans that supplement federal Medicare coverage for Americans over 64.
Kat Knoxsah, a pharmacy technician at the Stormont Vail Retail Pharmacy collects medications to fill prescriptions in Topeka, Kan., Tuesday, June 2, 2026. (AP Photo/John Hanna)
Kat Knoxsah, a pharmacy technician fills a prescription at the Stormont Vail Retail Pharmacy in Topeka, Kan., Tuesday, June 2, 2026. (AP Photo/John Hanna)
Bottles of medications sit on shelves at the Stormont Vail Retail Pharmacy in Topeka, Kan., Tuesday, June 2, 2026. (AP Photo/John Hanna)
HOUSTON (AP) — Tiny Cape Verde defied odds to become the smallest country to earn a spot in the World Cup knockout round behind the stellar play of Vozinha, the 40-year-old goalkeeper who embodied the grit of his nation.
“We are small,” he said. “But we have big hearts and we are fighters.”
Cape Verde completed an improbable run through the group stage with a third straight World Cup draw, a 0-0 draw against Saudi Arabia on Friday night to advance in the tournament.
The small island nation off the western coast of Africa, which is making its debut on soccer’s grandest stage, already held 2010 champion Spain to a 0-0 draw and then came from behind to get a 2-2 result against Uruguay.
“The team was very eager to show this to the whole world,” Cape Verde coach Bubista said while draped in his country's flag. “We are proud of having arrived at this stage. We have shown that we are a small country, but that we fight for the things that we want to achieve.”
Cape Verde’s three points put the team in second place behind Spain, which beat Uruguay on Friday night and won the group.
Cape Verde will play reigning World Cup champion Argentina in Miami on July 3.
Drawing all three group matches doesn't guarantee advancement at major soccer tournaments. But several teams have done it in the past, including Wales in 1958, Ireland and the Netherlands in 1990, and Chile in 1998. New Zealand, however, also got three draws at the 2010 World Cup and was eliminated.
On the eve of the match, Bubista mused, “everyone is entitled to dream and nothing is impossible.”
The Blue Sharks proved him right, overcoming seemingly insurmountable odds as this country of just more than 500,000 reached the round of 32.
A woman, her face painted with a flag of the archipelago, held a sign that read: “Small Islands, Big Dreams.”
A dream that these underdogs have made reality as they continue their charmed run on the world stage.
They did it with another strong game from Vozinha, whose tournament success has helped him amass more than 16 million Instagram followers.
He had a save in first half stoppage time, grabbing a header from Mohamed Kanno to keep Saudi Arabia scoreless. Another save came in the 66th minute when he leaped to deflect a shot from Mohammed Abu Al-Shamat.
A third came in the 92nd minute when he stopped a shot by Abdullah Al-Hamdan.
“There is a lot of quality in our national team,” Vozinha said. “Maybe for many of you, you think the Cape Verdean player is not good enough. But we came here to show that we have a lot of quality and we are here to compete and our players can play everywhere in the big competition, in the big leagues.”
A group of shirtless men in the crowd each painted one letter of his name on their chests as they cheered Cape Verde.
But Vozinha had a much bigger fan among the crowd of 68,278 as his mother Ana Candida Evora watched from a luxury suite, waving a tiny Cape Verde flag. It was her second match of the tournament after missing Vozinha’s epic seven-save performance against Spain because of visa issues.
Cape Verde had a chance to score in the 50th minute, but Kevin Pina's shot from distance was just above the crossbar. Another chance came in the 74th minute when Laros Duarte’s shot from the middle of the box was stopped by goalkeeper Mohammed Al-Owais.
A last chance to score came in the final seconds when Nuno da Costa sent a shot from the middle of the box wide left.
But it didn’t matter because a couple of minutes after the final whistle, Spain completed its victory over Uruguay and set off a joyous celebration among Cape Verde's players and fans, many of whom cried as they rejoiced.
Having led his squad to new heights, Bubista was asked if he could have imagined such a run entering the tournament.
“I’ve always said that sooner or later Cape Verde would be on such a stage,” he said. “Of course it’s hard to have such a forecast, but I always knew.”
Saudi Arabia was eliminated after finishing with two points in the group stage.
“We were very poor in terms of creating things, controlling the game and creating actions,” coach Georgios Donis said. “And one cannot win a game this way. It would be very difficult.”
See more of AP’s World Cup coverage here
Cape Verde head coach Bubista waves the flag as he celebrates with fans after their 0-0 draw against Saudi Arabia after the World Cup Group H soccer match in Houston, Friday, June 26, 2026. (AP Photo/David J. Phillip)
Cape Verde head coach Bubista waves a flag while being carried on the shoulder of Jovane Cabral (7) during the World Cup Group H soccer match between Cape Verde and Saudi Arabia in Houston, Friday, June 26, 2026. (AP Photo/Eric Gay)
Cape Verde goalkeeper Marcio Rosa (12) celebrates with teammates after advancing during the World Cup Group H soccer match between Cape Verde and Saudi Arabia in Houston, Friday, June 26, 2026. (AP Photo/Eric Gay) CORRECTION: Corrects ID to Cape Verde goalkeeper Marcio Rosa (12), not Cape Verde goalkeeper Vozinha (1).
Cape Verde team members celebrate after the World Cup Group H soccer match between Cape Verde and Saudi Arabia in Houston, Friday, June 26, 2026. (AP Photo/Ashley Landis)
Saudi Arabia's Mohamed Kanno (23) battles for the ball with Cape Verde's Nuno da Costa (21) during the World Cup Group H soccer match between Cape Verde and Saudi Arabia in Houston, Friday, June 26, 2026. (AP Photo/Ashley Landis)
Cape Verde's Diney Borges (3) slides under Saudi Arabia's Mohammed Abu Alshamat (26) during the second half of the World Cup Group H soccer match between Cape Verde and Saudi Arabia in Houston, Friday, June 26, 2026. (AP Photo/David J. Phillip)
Saudi Arabia's Ali Lajami (3) battles for a header on a corner kick with Cape Verde's Diney Borges (3) during the World Cup Group H soccer match between Cape Verde and Saudi Arabia in Houston, Friday, June 26, 2026. (AP Photo/Eric Gay)
Saudi Arabia goalkeeper Mohammed Alowais (21) and Cape Verde's Laros Duarte (15) look on as the ball goes wide after Alowais made a save during the World Cup Group H soccer match between Cape Verde and Saudi Arabia in Houston, Friday, June 26, 2026. (AP Photo/Ashley Landis)
Saudi Arabia's Abdulelah Alamri (4) and Cape Verde's Nuno da Costa (21) collide was they try to head the ball during the second half of the World Cup Group H soccer match in Houston, Friday, June 26, 2026. (AP Photo/David J. Phillip)
