PBM Settlements Won’t Enforce Themselves: Here’s What to Watch

Pharmacy benefit managers have been playing cat and mouse with regulators for years now, and by most measures, they've been winning. The pattern is familiar enough: scrutiny builds, a PBM announces sweeping reforms, the money moves to a new subsidiary, and business continues.

Federal regulators have now reached proposed settlements with three of the country's largest PBMs, a notable victory that follows substantial Congressional action earlier this year. But the history here warrants skepticism. The distance between a proposed settlement and actual change in what patients pay at the pharmacy counter is considerable, and that distance is where PBMs have historically operated most comfortably.

The level of enforcement and oversight of these terms will determine their effectiveness in delivering the accountability that patients, employers, and taxpayers are owed. Below is a breakdown of what the settlements require and where critical questions remain.

FTC – PBM Settlement Comparisons

Between February and June 2026, the Federal Trade Commission (FTC) secured proposed settlements with three of the nation's largest PBMs: Express Scripts (Cigna/Evernorth), CVS Caremark and OptumRx (UnitedHealth Group). This action reportedly resolved a 2024 enforcement action that alleged the Big Three PBMs had engaged in anticompetitive rebating practices that artificially inflated insulin list prices and drove up out-of-pocket costs for millions of American patients. The settlements, modeled on the Express Scripts agreement, require the PBMs to overhaul core business practices: delinking compensation from list prices, passing rebates through to patients at the point of sale, basing patient cost-sharing on net rather than list price and reimbursing independent pharmacies at actual acquisition cost. 

The chart below includes additional, publicly available information about the settlements.

Issue	Express Scripts	Caremark	OptumRx
Delink compensation from list prices	✅ Required	✅ Expected	🔄 Likely
Net-cost-based patient OOP	✅ Required	✅ Expected	🔄 Likely
Rebate pass-through at point of sale	✅ Required	✅ Expected	✅ Self-committed
Pharmacy reimbursement reform	✅ Required	✅ Expected	🔄 Likely
GPO transparency / repatriation	✅ Required (Ascent → US)	🔄 TBD	🔄 TBD
Compliance monitor	✅ 3 years	🔄 TBD	🔄 TBD

Key Takeaways

Note: Proposed settlement for Caremark has been filed, but the full consent order had not yet been publicly released. The OptumRx settlement has been approved at the FTC, but formal public disclosure of the specific terms has not yet been made.

Express Scripts – Finalized February 4, 2026 

The settlement imposes business-practice changes that extend beyond insulin and apply to Express Scripts’ broader formulary, rebate and pharmacy reimbursement practices. The FTC estimates the settlement could reduce patient out-of-pocket drug costs by up to $7 billion over 10 years. Close monitoring of PBM practices, however, is necessary to ensure that any savings are passed along to patients and are not simply shifted to affiliated PBM subsidiaries.

Specific terms effective January 1, 2028

• Formulary design: When a manufacturer offers therapeutically equivalent high-list-price and low-list-price versions of a drug, Express Scripts cannot favor the high-list-price version on its standard formulary through more favorable placement or utilization management restrictions.

• Out-of-pocket cost cap: Under the settlement, Express Scripts agreed to roll out a standard formulary offering in which the out-of-pocket expenses for patients are based on a drug’s net cost, rather than the list price.

• Rebate pass-through: Members receive the benefit of any negotiated rebates at the point of sale with no additional fees charged.

• No spread pricing: Express Scripts may not employ spread pricing – pocketing the difference between what a plan sponsor pays Express Scripts and what Express Scripts pays to a pharmacy.

• Pharmacy compensation: Retail pharmacies must be compensated based on actual acquisition cost plus a dispensing fee.

• Delinked compensation: Express Scripts must delink its compensation from the savings it negotiates with pharmaceutical companies and must stop preferring medications with high list prices.

• GPO repatriation: The company must move Ascent, its group purchasing organization, back to the United States from Switzerland.

• Transparency: Express Scripts must provide plan sponsors with automated annual reporting on costs per drug and claim-level data, plus full disclosure of compensation paid to consultants or brokers.

• Compliance monitor: A compliance monitor will oversee Express Scripts for three years; the order remains in effect for 10 years.

CVS Caremark – Proposed March 23, 2026 

The FTC and CVS Caremark jointly moved to withdraw from the adjudicative proceeding to allow the Commission to consider a proposed settlement agreement. This agreement closely follows the precedent set by Express Scripts’ settlement, requiring a comprehensive overhaul of rebate practices.

CVS Caremark made similar concessions to Express Scripts, with the FTC promising that the deals would reduce the price of insulin significantly over time. The settlement details, announced July 14, required similar changes to formulary design, rebate treatment, PBM compensation structures, pharmacy reimbursement, GPO repatriation, and reporting transparency.

OptumRx – Proposed June 12, 2026 

UnitedHealth’s OptumRx has reached a tentative settlement with the FTC, joining CVS Health’s Caremark and the Cigna Group’s Express Scripts, which agreed to settlements earlier in 2026. The proposed consent agreement with OptumRx has been approved by directors of the FTC’s Bureaus of Competition and Consumer Protection, although details of the agreement have not been disclosed.

It’s not yet clear what specific changes to its business practices OptumRx will need to make, though those details should be made public once the FTC makes a formal announcement. OptumRx has separately announced several business-model changes that appear directionally consistent with the FTC’s concerns, including increased pricing transparency, movement away from rebate-based compensation and pass-through of manufacturer rebates to clients.