PBMA Applauds FTC’s Proposed Order Against Express Scripts

PBM Accountability Project recently submitted a comment to the Federal Trade Commission strongly supporting its proposed Decision and Order against Express Scripts, Inc., Evernorth Health, Inc., Medco Health Services, Inc., and Ascent Health Services LLC. As a coalition of leaders and stakeholders across healthcare, labor, business, pharmacy, and patient and consumer advocacy, we view this enforcement action as a critical step toward restoring transparency, fairness and accountability in our health system. For too long, patients, independent community pharmacies, employers and plan sponsors have felt the costs of anticompetitive and opaque PBM practices. The FTC’s proposed Order begins to address these harms, and we urge the Commission to finalize it without dilution, appoint a rigorous and qualified monitor and use this action as the foundation for broader industry-wide reform. 

Addressing Core PBM Abuses 

The proposed decision tackles core PBM anti-competitive conduct. Each provision responds to a well‑documented harmful practice:  

• PBMs favoring high‑list‑price 

• High‑rebate drugs over lower‑cost alternatives 

• Tying patient cost‑sharing to inflated list prices instead of the true net cost 

• Using spread pricing that allows PBMs to charge payers more than they reimburse pharmacies 

• Maintaining opaque compensation arrangements that obscure how much PBMs keep; and underpaying or excluding independent community pharmacies in ways that fuel pharmacy closures and reduce access to care.  

  
  

Together, reforms outlined in the decision would help realign PBM incentives with the interests of patients, plan sponsors and local pharmacies by curbing the most distortive business practices that drive costs and restrict access. 

Strengthening and Extending the Order 

While we support the Order as written, we offer several recommendations to ensure its provisions work as intended in practice. 

1. The Commission should extend its core protections to other dominant PBMs so that patients and plan sponsor nationwide benefit, not just those whose plans contract with Express Scripts.  

2. Implementation timelines should be accelerated where feasible so that critical safeguards—such as changes to cost‑sharing and protections for independent pharmacies—are not delayed until 2028.  

3. The FTC should also coordinate closely with Congress and state regulators to align oversight and make full use of the factual record developed in this case and should be prepared to impose meaningful financial penalties if ESI fails to comply with the Order’s requirements.  

   
   

These steps would help ensure the settlement drives lasting structural change in how PBMs operate. 

A Pivotal Step Toward PBM Reform 

The proposed Order against Express Scripts is one of the most significant federal actions to date aimed at curbing harmful PBM practices that raise costs and limit access to medicines. 

It directly targets documented abuses and begins to realign PBM incentives with the needs of patients and plan sponsors.  

Read our full comment letter here.