FTC’s Back-to-Back PBM Settlements Force Real Transparency
FTC settlements with Express Scripts and CVS Caremark are forcing structural transparency into PBM operations — here’s what changes and when.
Back-to-back FTC settlements with Express Scripts and CVS Caremark are forcing what the industry has discussed for years but rarely achieved: real, structural transparency into PBM operations and how drug pricing actually flows from manufacturer to patient.
What the Settlements Require
The FTC secured its settlement with Express Scripts on February 4, 2026, requiring fundamental changes to its business practices that are expected to drive down patients’ out-of-pocket insulin costs by up to $7 billion over 10 years, while bringing new revenue to community pharmacies. CVS Caremark’s settlement, reached in July 2026, closely follows the same precedent — requiring a comprehensive overhaul of rebate practices, delinking PBM fees from drug list prices, and opening the door to fairer cost-plus reimbursement models for retail community pharmacies. Optum Rx has a proposed consent agreement pending as of mid-2026, not yet finalized.
The Bigger Structural Shift
According to Rae McMahan, senior vice president of payor solutions at Prescryptive Health, the real story isn’t any single settlement — it’s that everybody in the PBM ecosystem now needs to operate transparently. The settlements align with the Consolidated Appropriations Act of 2026, which separately mandates 100% rebate pass-through and bans spread pricing in Medicare Part D starting in 2028-2029. Together, industry observers describe this as establishing a “fiduciary PBM” standard that pressures the entire market, not just the three named companies.
What This Means for Access & Formulary Teams
Optum Rx’s pending settlement is the one to watch. Until Optum finalizes its consent agreement, formulary and contracting teams working with Optum should anticipate similar transparency requirements arriving on a lag relative to Express Scripts and Caremark.
Compliance monitoring adds real teeth. Express Scripts faces a three-year compliance monitor under a 10-year order — this isn’t a one-time settlement, it’s ongoing oversight that should factor into long-term contract planning with the PBM.
Community pharmacy economics are shifting favorably. With settlements explicitly aimed at bringing new revenue to community pharmacies through fairer reimbursement, independent and community pharmacy partners may become more commercially viable channel options than they were pre-settlement.
FAQ
What did the FTC settle with Express Scripts and CVS Caremark over?
The FTC alleged the three largest PBMs engaged in anticompetitive and unfair rebating practices that artificially inflated insulin list prices; the settlements require transparency reforms and changes to rebate and reimbursement practices.
Has Optum Rx settled with the FTC?
Not yet as of mid-2026 — Optum reached a tentative proposed consent agreement in June but has not finalized a settlement, unlike Express Scripts and CVS Caremark.
How does the Consolidated Appropriations Act of 2026 relate to these settlements?
CAA 2026 separately mandates 100% rebate pass-through and bans PBM spread pricing in Medicare Part D starting 2028-2029, reinforcing the same transparency direction as the FTC settlements at a legislative level.
Sources
- Drug Topics, Q&A: FTC Settlements, PBM Reform Are Reshaping Transparency Standards
- FTC, Pharmacy Benefits Managers (PBM)
- Managed Healthcare Executive, A Landmark Shift in Healthcare: Insights from MHE and Drug Topics’ Webinar on PBM Reform
- PBM Accountability, PBM Settlements Won’t Enforce Themselves: Here’s What to Watch