For years, the price you pay at the pharmacy counter has been part of a complex, often invisible game played by powerful middlemen. Now, federal regulators have stepped in to change the rules.
The Federal Trade Commission (FTC) announced a landmark settlement with Express Scripts, one of the largest pharmacy benefit managers (PBMs) in the nation. The deal resolves allegations that the company artificially inflated drug prices — specifically for lifesaving medications like insulin — to boost its own profits at the expense of patients.
If you get your prescriptions through Express Scripts or use a community pharmacy, here’s how this settlement could lower your bills.
The end of artificially inflated list prices
The core of the FTC’s complaint focused on a practice that punished patients to reward the PBMs. According to regulators, Express Scripts prioritized drugs with high list prices because those drugs came with larger rebates from manufacturers.
While the PBM pocketed the rebates, patients were often stuck paying coinsurance or deductibles based on that artificially inflated list price.
Under the new settlement, Express Scripts is banned from excluding lower-cost drugs from its standard formularies in favor of higher-cost versions just to harvest rebates.
This move is expected to save patients up to $7 billion over the next decade by ensuring they have access to cheaper medications that were previously blocked.
Lower costs at the counter
The settlement forces a shift in how your costs are calculated. Express Scripts must now offer plan options where your out-of-pocket expenses are based on the drug’s net cost (the actual price after discounts and rebates), rather than the high list price.
Additionally, the agreement expands access to the Patient Assurance Program, which caps out-of-pocket costs for insulin at $25 per month. If your plan covers an eligible insulin product, Express Scripts must now offer this cap as a standard benefit unless your plan sponsor explicitly opts out.
Integration with TrumpRx
As part of the settlement terms, Express Scripts is required to provide covered access to TrumpRx, a new direct-to-consumer pricing platform.
Once the necessary regulatory framework is established, Express Scripts must include this platform as part of its standard offering. This inclusion is intended to allow patients to access the platform’s negotiated cash prices while still having those payments count toward their insurance deductibles and out-of-pocket maximums.
Reshoring international operations
The agreement also targets the corporate structure of Express Scripts’ supply chain. The company must reshore its Switzerland-based group purchasing organization, Ascent Health Services, to the United States.
Regulators have scrutinized offshore purchasing units for years due to concerns about transparency and tax avoidance. By moving Ascent back to U.S. soil, the FTC aims to bring over $750 billion in purchasing activity under tighter domestic regulatory oversight.
A boost for community pharmacies
The deal also addresses how Express Scripts interacts with local pharmacies. Independent and community pharmacies have long complained that PBMs reimburse them at unfairly low rates while steering patients toward the PBMs’ own mail-order services.
The settlement requires Express Scripts to pay retail community pharmacies based on a transparent formula: the actual acquisition cost of the drug plus a dispensing fee. This change is designed to stop the financial squeeze on local pharmacies and ensure they can remain in business to serve you.
What happens next
This agreement specifically applies to Express Scripts and its affiliated entities. However, the FTC currently has ongoing litigation against other major PBMs, including Caremark and OptumRx.
This settlement sets a significant precedent that could signal broader changes across the entire pharmaceutical industry, potentially unraveling the rebate-driven model that has defined drug pricing for decades.
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