US-Rx Care says early-2026 PBM action elevated disclosure, auditability, and fiduciary accountability, even as many of the contract structures and revenue streams that drive employer drug costs remain in place.
HOLLYWOOD, Fla.,– With PBM reform moving from policy debate to active scrutiny, US-Rx Care says self-funded employers are facing a more demanding oversight environment even though many of the mechanisms that drive pharmacy overspend remain intact. For plan sponsors entering renewal season, the issue is no longer simply whether PBMs are under pressure. It is whether employers can justify renewing into contracts that preserve the same conflicts regulators, lawmakers, and purchasers are now questioning.
“Employers do not have to wait for every rule to be finalized or every case to be litigated. They can demand fiduciary alignment now and remove those conflicts directly from the way they purchase pharmacy benefits.” – Renzo Luzzatti, CEO of US-Rx Care
“Employers do not have to wait for every rule to be finalized or every case to be litigated. They can demand fiduciary alignment now and remove those conflicts directly from the way they purchase pharmacy benefits.” – Renzo Luzzatti, CEO of US-Rx Care
“The story now is not just that PBMs are under pressure,” said Renzo Luzzatti, CEO of US-Rx Care. “It’s that employers are also under pressure to prove they are buying and governing pharmacy benefits prudently, even before the final reform picture is clear.”
Reform Raises the Stakes for Employers
Early this year, Congress enacted PBM-related reforms in the Consolidated Appropriations Act of 2026. The Department of Labor also proposed a PBM fee-disclosure rule for Employee Retirement Income Security Act (ERISA) self-insured plans, while employer groups publicly backed stronger claims-data access. Add the FTC’s February settlement with Express Scripts, the employer story has evolved beyond generic PBM criticism. It is now a fiduciary and governance issue, especially for CFOs, CHROs, benefits committees, and procurement teams responsible for overseeing pharmacy spend.
US-Rx Care argues that the proposed transparency and reporting requirements would not take effect until 2028 and, like earlier disclosure efforts, may be heavily litigated or never implemented. That leaves employers in a difficult position: expectations around oversight are rising now, while the final legal and regulatory framework is still being worked out.
Why Reform Headlines Do Not Equal Protection
Many of the structural levers that inflate employer drug spend still appear to remain in place. According to US-Rx Care, these include vertically integrated pharmacy ownership, exclusive arrangements that lock plans into PBM-controlled services, rebate-linked economics, prior authorization control, and contract terms that allow PBMs to profit when overall plan costs rise. That disconnect is what makes the current moment risky for employers: reform headlines can suggest the market is getting safer, even while the underlying economics remain largely unchanged.
US-Rx Care says the most important disclosures are often the ones legacy PBM arrangements resist most such as total PBM revenue from all sources, manufacturer revenue by any definition, including discounts tied to drugs dispensed through PBM-owned pharmacies, and compensation paid to third parties. The company says those hidden revenue streams are often the source of conflicts working against plan sponsors and plan members.
“Before employers can fix the economics, they have to see the economics,” Luzzatti said. “Who gets paid, how they get paid, and whether higher plan spend still produces higher PBM profit. Those are the questions that matter.”
What Employers Should Demand in the Next Renewal
US-Rx Care believes that employers need to move beyond transparency of language and toward fiduciary standards. “Transparency is not a legal term. It can mean whatever the PBM wants it to mean,” Luzzatti said. “Fiduciary, by contrast, has a legal definition under ERISA. If a PBM is not obligated to act in the plan’s best interest, then transparency alone does not solve the conflict.”
For employers evaluating a prudent 2026 PBM renewal process, the key questions are straightforward:
Is the PBM fully aligned with the employer’s fiduciary obligations under ERISA?
Does the PBM make more money when plan costs rise?
Does the PBM own retail, mail, or specialty pharmacies that the plan is incentivized or required to use?
Can the best interests of the plan negatively affect the PBM’s profits?
These questions separate true employer protection from performative transparency.
US-Rx Care says employers should closely examine contract language that:
explicitly states the PBM is not a fiduciary
limits fiduciary duties to claims or appeals functions
restricts the use of third-party solutions
preserves exclusive control over clinical services and dispensing channels
Permits spread pricing
defines rebates too narrowly to capture all manufacturer revenue.
In the company’s view, those are the provisions that often preserve PBM leverage even in a reform-heavy environment.
US-Rx Care maintains that a fiduciary PBM model changes the structure in ways proposed reforms still may not. It points to no conflicts of interest, no pharmacy ownership, no hidden markups or spread pricing, no retained manufacturer revenue, simple administrative fees as the sole source of revenue, formularies designed around clinical and financial parameters to drive the lowest net cost, and open pharmacy networks that allow plans to access lower-cost sources when appropriate.
“Government action has made one thing clear: turning a blind eye to well-documented PBM conflicts is no longer a tenable strategy,” Luzzatti said. “But employers do not have to wait for every rule to be finalized or every case to be litigated. They can demand fiduciary alignment now and remove those conflicts directly from the way they purchase pharmacy benefits.”
About US-Rx Care
US-Rx Care is revolutionizing America’s pharmacy benefits system by replacing opaque, profit-driven PBMs with a transparent, fiduciary model that puts employers and members first. Founded in 2007, the company combines clinical rigor, ethical contracting, and data-driven oversight to cut drug costs by up to 50% or more while also improving health outcomes. Operating under a legally binding ERISA fiduciary standard, US-Rx Care eliminates conflicts of interest, passes through 100% of manufacturer rebates and pharmacy discounts, and delivers measurable savings without compromising care. Privately owned and free from outside financial influence, US-Rx Care is setting the new standard for pharmacy benefit management—restoring trust, accountability, and real control for employers, benefits consultants, and health plans nationwide. Website: www.us-rxcare.com
References:
S. Department of Labor. (2026, January 29). US Department of Labor proposes historic pharmacy benefit manager fee disclosure rule. Dol.gov/newsroom/releases/ebsa/ebsa20260129
Early into Q1-2026, some major changes were brought to pharmacy benefits. The Federal Trade Commission (FTC) reached a major settlement with Express Scripts, Congress passed new pharmacy benefit manager (PBM) reform laws, and the Department of Labor proposed new rules requiring more transparency about PBM payments.
Together, these actions move PBM reform from just a policy discussion to something that employers and health plans will need to actively manage and monitor. Here’s what changed and why it matters:
FTC Settlement with Express Scripts: The settlement requires Express Scripts to stop tying its compensation to the price of drugs, offer transparent “pass-through” pricing, calculate patient cost-sharing based on the drug’s net price instead of the higher list price, and provide drug-level reporting to plan sponsors. The FTC estimates this could save up to $7 billion on insulin alone over 10 years. Similar cases involving Caremark and OptumRx are scheduled for hearings in June 2026.
New PBM Reform Law in the 2026 Federal Spending Bill: The law requires PBMs to pass 100% of manufacturer rebates back to health plans and insurers. It also requires PBMs to send rebates to plans quarterly, with full rights for plans to audit the payments. However, PBM ownership of pharmacies (specialty, mail, or retail) is not prohibited, nor are fees for rebate aggregation. It also attempts to make PBMs “covered entities” and thus accountable under ERISA and, in turn, subject to fines for non-compliance. These regs would not kick in until 2028, and like the below transparency rules, are likely to be heavily litigated between now and then.
Proposed Department of Labor Transparency Rules: PBMs would have to disclose all forms of compensation they receive, including rebates from manufacturers, spread pricing revenue, group purchasing organization (GPO) income, and payments through related companies, to employer health plans governed by ERISA. If PBMs fail to disclose this information, the contract could be considered a prohibited transaction under ERISA.
Launch of TrumpRx: A new government website offering direct-to-consumer discounts on 43 brand-name drugs, including GLP-1 medications. These are cash-pay options only and do not work with employer health plans, so the immediate impact on employer benefits is limited but worth watching. That said, there are multiple emerging avenues for employer self-funded plans to access the “cash prices,” a welcome development of interest to US-Rx and our clients.
Launch of Oral Wegovy: The first daily pill version of a GLP-1 weight-loss drug is now available. Another oral GLP-1, orforglipron, may receive FDA approval in Q2 2026, which could further increase demand for these medications.
Bottom Line for Plan Sponsors
Fiduciary responsibility around pharmacy benefits is no longer optional. Employers now need to make sure their PBM arrangements are transparent and meet stricter disclosure requirements. If they don’t, they could face compliance risks under ERISA.
The traditional rebate-driven PBM model is also starting to fade. The industry is being forced toward more transparent approaches, like pass-through pricing, PBM payments that aren’t tied to drug prices, and benefit designs based on the drug’s net cost rather than the higher list price. What this will all translate into practice after being litigated in the courts has yet to be seen.
Quarterly Pulse: Trends Shaping the Next 90 Days
The Express Scripts Settlement: What Employers Need to Know Now
In February 2026, the Federal Trade Commission (FTC) announced what it described as a major settlement with Express Scripts. The FTC had accused the company of helping drive up the list prices of insulin and other drugs by using rebate practices that limited competition.
Although the case focused mainly on insulin, the changes required under the settlement apply to all drugs managed by Express Scripts. Because of its broad impact, this is considered one of the most significant regulatory actions against a pharmacy benefit manager (PBM) in decades.
Key Settlement Provisions
Net-Price Benefit Design: Express Scripts must offer plans under which the amount patients pay (copays, coinsurance, or deductibles) is based on the actual net price of the drug, not the higher list price. This helps prevent patients from paying inflated out-of-pocket costs tied to high list prices.
Formulary Reform: Express Scripts can no longer structure its standard formulary in a way that favors high-list-price drugs over lower-priced versions of the same medication. This is meant to stop the so-called “rebate trap” that has historically made it harder for lower-cost biosimilars and generics to compete.
Delinked Compensation: Payments that Express Scripts receives from drug manufacturers can no longer be tied to the price of the drug. This removes the incentive to prefer drugs with higher list prices simply because they produce bigger rebates.
Pass-Through Pricing: Express Scripts must give plan sponsors the option to move away from rebate guarantees and spread pricing. Starting in 2028, the company will also need to pass rebates and discounts directly to patients at the pharmacy counter as its standard model.
Transparency and Reporting: Express Scripts must provide automated, drug-level reporting to plan sponsors, including annual cost reports and claim-level data. This helps employers better understand their pharmacy spending and evaluate whether their PBM arrangement meets ERISA fiduciary expectations.
GPO Relocation: Express Scripts’ group purchasing organization, Ascent Health Services, must move its negotiation operations, not its headquarters, from Switzerland to the United States.
Compliance Monitor: An independent monitor will oversee Express Scripts’ compliance with the settlement for three years.
The settlement also requires Express Scripts to assist the FTC in its ongoing case against CVS Caremark and OptumRx, including providing witnesses for depositions and trial. A key evidentiary hearing for those two PBMs is scheduled in June 2026.
What This Means for Employers
If your plan uses Express Scripts, you should expect meaningful changes to how formularies are designed, how drugs are priced, how reporting is provided, and the fee structure starting in 2028. Employers should take a proactive look at their PBM contracts and evaluate what it would mean financially to move away from a rebate-driven model to a fee-for-service PBM structure.
If your plan uses Caremark or OptumRx, the Express Scripts settlement could signal what’s coming next. CVS has already indicated it is in discussions with regulators. Employers may want to begin reviewing their PBMs ’ level of transparency and fiduciary alignment now rather than waiting for regulatory changes to force the issue.
For employers overall, the settlement reinforces practices that fiduciary-focused PBMs, such as US-Rx Care, have already adopted. Models built around de-conflicted compensation, pass-through pricing, and full transparency are no longer unique features; they are quickly becoming the minimum standard expected by regulators and plan sponsors alike.
TrumpRx: Headline Grabber or Game Changer?
Launched after the Express Scripts settlement, TrumpRx is a new website that gathers manufacturer discounts and coupons for 43 brand-name drugs and makes them available directly to consumers. The platform advertises large cash discounts on well-known medications such as Wegovy, Zepbound, Ozempic, insulin products, fertility drugs, and treatments for autoimmune conditions.
Some of the pricing looks dramatic, for example, oral Wegovy is listed at about $149 per month compared to a $1,349 list price. However, employer plan sponsors should understand a few important limitations:
Cash-Pay Only: These discounts are intended only for people paying out of pocket. Purchases made through TrumpRx are not intended to go through employer insurance and do not count toward deductibles or out-of-pocket maximums.
Not an Online Pharmacy: The site doesn’t sell drugs itself. It simply gathers coupons and redirects users to manufacturer websites or pharmacy partners where they can buy the medication.
Limited List of Drugs: Right now, the platform only includes 43 medications. Most prescriptions in the U.S. are for generics, and those are not included. Many of the drugs listed are brands for which generics have been on the market for decades.
Separate from Employer Health Plans: Unless new laws are passed allowing these purchases to be covered under health plans, TrumpRx doesn’t really integrate with employer benefits. A proposal called the “Great Healthcare Plan” could change that, but it hasn’t been passed. That said, the Express Scripts settlement specifically says that Express Scripts is expected to access Trump Rx prices, which suggests future intent to open these cash prices directly to self-insured employers’ plans. As noted above, there are multiple options emerging to achieve that end today.
For employers, the biggest issue may be employee confusion. People might see much lower prices for drugs like GLP-1s on TrumpRx and wonder why their insurance plan appears more expensive. Clear communication will be important to explain why insurance copays can differ from cash-pay manufacturer discounts.
US-Rx Care Perspective
TrumpRx is essentially a coupon website, like GoodRx, but with government branding. However, the direct-to-consumer cash prices offer deeper discounts than are achieved through discounts, rebates, and copay assistance, so access to those prices for employers offers good value.
For employer health plans, the Express Scripts settlement represents a potential sea change for the traditional PBM model. As do the Department of Labor’s proposed transparency rules and the PBM reforms included in the 2026 Consolidated Appropriations Act. Those changes are likely to have a significant impact on how pharmacy benefits are priced, managed, and monitored going forward unless they are shot down or watered down through litigation.
DOL’s ERISA Proposed Rule: The Fiduciary Reckoning
In January 2026, the U.S. Department of Labor proposed new rules under the Employee Retirement Income Security Act of 1974 (ERISA) that would require pharmacy benefit managers (PBMs), along with related brokers and consultants, to clearly disclose how they are paid to the employers who oversee self-insured health plans. This is the first time the Department of Labor has applied its service-provider transparency rules directly to PBMs.
Under the proposal, PBMs would have to disclose things like:
What pharmacy benefit services do they provide
What does the health plan pay them directly?
Funds they receive from drug manufacturers and rebate aggregators
Revenue from spread pricing, group purchasing organization (GPO) arrangements, and payments involving related companies
Any compensation paid to affiliated brokers or consultants
These disclosures would need to be provided before signing a service contract and then updated twice a year.
Importantly, if a PBM does not provide these disclosures, the contract may no longer qualify for an exemption under ERISA’s prohibited transaction rules. That means the contract itself could be considered a violation of ERISA, and plan fiduciaries (the employers responsible for the plan) could potentially face personal liability if they fail to obtain or act on the information.
Separately, the Consolidated Appropriations Act of 2026 reinforces these transparency efforts. It requires PBMs to pass through 100% of manufacturer rebates to health plans and insurers, send those payments quarterly, and allow plans to audit the payments. If PBMs fail to follow these requirements, it can create another type of prohibited transaction risk under ERISA.
Action Items for Plan Fiduciaries
Take a close look at your current PBM contract. Does it clearly show how the PBM is paid, allow your plan to audit the financials, and ensure that all manufacturer revenue, not just “rebates,” is passed back to the plan? If not, it may be a good time to start that conversation with your PBM. If the PBM makes more money when the plan costs go up, that should also be a reason for concern.
Comments on the proposed rule from the U.S. Department of Labor are due April 2026. If the rule is finalized as written, it would apply to health plan benefit years starting on or after July 2028.
Employers working with a fiduciary PBM such as US-Rx Care may already be well-positioned for these changes. The company has operated under a fiduciary model since 2007, built around full transparency, no spread pricing, no keeping rebates, and avoiding conflicts of interest. To date, US-Rx Care has been compliant both before and after all State and Federal regulations aimed at the traditional PBM model.
From the Pharmacist’s Desk
GLP-1s in 2026: The Coverage Crossroads
GLP-1 drugs are now the single biggest factor driving employer pharmacy costs. With the daily oral Wegovy available, Eli Lilly’s orforglipron possibly launching mid-year, and more medical uses approved beyond diabetes and weight loss, employers are under increasing pressure to set a sustainable coverage strategy.
What’s New in Q1 2026
Oral Wegovy Launched: The first daily pill for weight management, showing about 16.6% average weight loss in clinical trials. Taking away the injection requirement is expected to significantly increase demand.
Orforglipron Nears Approval: A new oral GLP-1 from Eli Lilly could be approved by the FDA in Q2 2026. As a small molecule, it may cost less to make, potentially lowering prices.
CagriSema (cagrilintide/semaglutide): Novo Nordisk’s next-generation dual-action injectable is in late-stage trials, with FDA decisions expected in 2026.
Expanding Indications: Beyond diabetes and weight loss, GLP-1s now have approvals for cardiovascular risk reduction (Wegovy), obstructive sleep apnea (Zepbound), chronic kidney disease (Ozempic), and MASH/liver fibrosis (Wegovy).
The Employer Coverage Dilemma
Coverage is inconsistent among employers. Nearly 20% of large employers now cover GLP-1s for weight loss, especially the largest firms. But many employers are tightening coverage due to high costs.
List prices exceed $1,000/month, making GLP-1s a leading driver of pharmacy spending.
Manufacturers offer direct-to-consumer discounts of around $350–$500/month, and TrumpRx lists oral Wegovy at $149/month, creating noticeable price differences for members.
One Other Drug Class to Watch: Adalimumab Biosimilars
The adalimumab biosimilar market is at a turning point. By late 2024, biosimilars captured 23% of adalimumab prescriptions, mostly through co-branded strategies. With PBMs like ESI and Optum launching their own co-branded options and the FTC settlement requiring fair access, biosimilars should become easier to use.
However, AbbVie’s newer drugs, Skyrizi and Rinvoq, now outsell biosimilars by more than 8 to 1, reducing the market for adalimumab biosimilars. Employers need to ensure formularies capture biosimilar savings while also managing spending on Skyrizi and Rinvoq.
For plans that haven’t adopted a biosimilar-first strategy, recent regulatory changes (ESI settlement and CAA 2026) create a chance to act.
US-Rx Care has operated as a fiduciary PBM since 2007, following the same ERISA standards that govern plan sponsors. That means:
Fiduciary Commitment: US-Rx Care contractually acts in the best interest of the plan sponsor and its members. All decisions related to pharmacy benefit management are made with the sole objective of lowering costs and improving member outcomes, free from financial incentives that could conflict with the plan’s interests.
No Conflicts of Interest: US-Rx Care doesn’t make money from markups, rebates, spread pricing, or dispensing. It doesn’t own a mail-order or specialty pharmacy, and there are no manufacturing programs that create financial conflicts.
100% Pass-Through: All rebates and discounts from manufacturers go directly to the plan. This has always been the company’s approach, not something done in response to regulations.
Full Transparency: Employers get complete, drug-level reporting, exactly what the DOL now wants all PBMs to provide.
Proven Results: Clients often see 30–50%+ reductions in pharmacy spending without changing benefits or disrupting members.
With new federal rules essentially requiring what US-Rx Care has always done, employers renewing their PBM contract have a simple choice: partner with a PBM whose model is already built to be compliant and aligned with plan interests.
The Conference Collection
Q1 2026 US-Rx Care Pulse
The first few months of 2026 have been busy for the US-Rx Care team, including attending and speaking at several industry events across the pharmacy benefits landscape. Some industry events we’ve attended:
IFEBP Health Benefits Conference + Expo (Ponte Vedra Beach, FL | Jan 20–22)
Ascend (Nashville, TN | Jan 27–30)
You Powered Benefit Symposium (Savannah, GA | Feb 1–4)
Washington Health Alliance: Driving Accountability and Innovation in PBM (Seattle, WA | Feb 4)
National Labor Management Conference (Hollywood, FL | Feb 12–17)
HCAA Executive Forum (San Antonio, TX | Feb 23–25)
NABIP Capitol Conference (Washington, DC | Feb 23)
Advisory Board Meeting (Orlando, FL | Mar 2–4)
PayerAlly Employer & Health Plan Conference (New York, NY | Mar 17–19)
AHIP Medicare Conference (Washington, DC | Mar 23–25)
SIIA Spring Exchange (New Orleans, LA | Mar 30–Apr 1)
Q2 2026 Where You’ll Find the US-Rx Care Team
Looking ahead, the US-Rx Care team will continue engaging with employers, consultants, and healthcare leaders across the country to discuss pharmacy benefit strategy, cost management, and fiduciary PBM practices. Upcoming industry events include:
Southwest Benefits Association Conference (Oklahoma | May 6–8)
Florida Alliance Annual Conference (Orlando, FL | May 13)
Medicare Stars, HEDIS, Quality & Risk Summit (Chicago, IL | Jun 2–4)
GPBCH Annual Conference (Philadelphia, PA | Jun 4)
Ascend (Nashville, TN | Jun 8–9)
National Alliance of Healthcare Purchaser Coalitions Summit (St. Louis, MO | Jun 8–9)
NABIP Annual Convention (Atlantic City, NJ | Jun 27–30)
We look forward to connecting with employers, advisors, and industry partners throughout the year and hope to see many of you at these upcoming events.
Coming Soon Near You
As part of our continued commitment to delivering greater transparency, cost efficiency, and member experience, US-Rx Care is evaluating several enhancements targeted for implementation in 2026. These initiatives are designed to further strengthen plan performance while improving the pharmacy benefit experience for both plan sponsors and members.
Expanded Specialty Pharmacy Network Optimization
US-Rx Care is exploring the expansion of its specialty pharmacy network beyond our current 15 contracted specialty pharmacies to further strengthen our ability to identify the most cost-effective dispensing option for each specialty medication. By increasing network visibility and leveraging competitive pharmacy pricing, it is possible to ensure plans consistently access the lowest net cost specialty drug options while maintaining high standards of patient care and clinical oversight.
Enhanced Member Portal Experience
Enhancements to the member portal are in the works to provide members with greater real-time transparency and engagement with their pharmacy benefits. Planned improvements include expanded visibility into prior authorization status and other benefit details, allowing members to more easily track the progress of their prescriptions through the prior authorization process, as well as better understand their coverage, cost, and cost-saving alternatives.
Access to Manufacturer Direct Pricing
US-Rx Care is also evaluating expanded access to manufacturer-direct pricing opportunities. The goal is to provide access to medications at pricing negotiated directly with manufacturers, helping reduce overall drug costs while maintaining transparency in the supply chain and visibility as a plan sponsor.
Upcoming Webinar
Lastly, US-Rx Care is hosting a webinar on May 28 at 2:00 PM ET to cover the impact of the FTC settlement, PBM reform law, and DOL proposed rule for employers. Panelists include Darren Fogarty, Associate Director, Purchaser Value and Policy at PBGH, and Shawn Gremminger, President & CEO of the National Alliance of Healthcare Purchaser Coalitions.
The Federal Trade Commission’s recent settlement with Express Scripts quickly became one of the most discussed developments in the PBM industry. While the headlines focused on insulin pricing, the broader conversation is about something larger: the future of PBM accountability.
The announcement itself is not brand new. What becomes important over the following weeks is understanding the broader implications. As the initial reaction settles, employers and advisors are left with more practical questions about what this means for their own plans. That is why we are addressing it now.
At US-Rx, we believe these developments deserve thoughtful analysis, not quick commentary. The details of the settlement matter, but so does the larger conversation it prompts about incentives, transparency, and alignment in pharmacy benefits.
For employers and advisors, this is worth paying attention to. Not because it is dramatic, but because it brings long-standing structural concerns into public view.
You can review the FTC’s official announcement here.
Understanding the Core Allegations
The settlement addressed allegations that Express Scripts favored higher-cost branded insulins over lower-cost alternatives when building its formularies. The concern was that rebate arrangements tied to list prices may have influenced those decisions. To understand
why this connects directly to the future of PBM accountability, it helps to look at how many traditional PBM contracts operate.
Manufacturers often pay rebates that are calculated as a percentage of a drug’s list price. Higher list prices can produce larger rebate checks. Depending on the structure of a contract, a PBM may retain a portion of the rebate or incorporate it into pricing guarantees.
Over time, this can create tension within the model. If revenue is connected to list price magnitude, higher-priced drugs may generate more income than lower-cost options. Patients with deductibles or coinsurance often pay cost-sharing based on the list price rather than the net price after rebates. Employers may see pharmacy spend increase even when reported rebate totals appear substantial.
For organizations evaluating alternatives, many look toward a transparent pass-through pharmacy structure that removes retained rebate economics and aligns incentives more directly with total cost reduction. The regulatory attention surrounding this case reflects growing concern that incentive design, not just isolated decisions, can influence cost trajectories.
Why This Could Influence the Broader Market
Large PBMs operate complex, vertically integrated models. Rebates are only one piece of the equation, but they have historically played a meaningful role in revenue generation. If rebate practices face tighter oversight, PBMs may adjust how they generate margin. Specialty pharmacy, mail order dispensing, and administrative fee structures already represent significant revenue channels. Greater scrutiny of rebate economics could increase focus on those areas.
For employers, the important point is this: understanding a PBM relationship requires looking at the entire economic model. If one source of revenue tightens, another may expand. Alignment depends on how the model is built from the start.
This is why many plan sponsors choose to formally evaluate their PBM contract and overall incentive alignment rather than focusing on a single pricing lever.
The Regulatory Environment Is Evolving
This settlement arrives during a period of sustained federal and state interest in PBM practices. Other large organizations remain under investigation, and legislative proposals continue to circulate.
Employers are also more aware of pharmacy trend then they were even a few years ago. Pharmacy benefits now represent a significant and growing share of health plan costs.
Advisors are fielding more questions about transparency, oversight, and fiduciary responsibility. That broader environment makes this moment more consequential than a single enforcement action might suggest.
Questions Employers Should Be Asking
Events like this tend to prompt internal review, which is healthy.
Employers may want to revisit how their formularies are constructed and whether financial incentives influence drug placement. They may want to confirm that rebates are fully passed through and that spread pricing is eliminated. It is also worth examining where revenue is generated across specialty, mail order, and affiliated entities.
None of these questions are accusatory. They are part of responsible plan governance. Increased scrutiny raises the standard for understanding how pharmacy contracts operate.
Where the Fiduciary Model Differs
The concerns highlighted in the settlement revolve around incentive structure. When revenue depends on higher list prices, rebate retention, or dispensing spreads, employers may be exposed to costs that are not immediately transparent.
US-Rx was built with the future of accountability in mind.
Our compensation is not tied to drug list prices. We do not engage in spread pricing, and rebates are passed through in full. Revenue is structured to align with reducing total pharmacy spend for plan sponsors rather than benefiting from higher prices. You can learn more about our fiduciary pharmacy model here.
The economic structure is independent of manufacturer rebate magnitude and dispensing spreads; clients are insulated from many of the conflicts that have drawn regulatory attention.
Looking Ahead
The Express Scripts settlement will not resolve every rebate surrounding PBM practices. It does, however, bring incentive alignment into sharper focus for regulators, employers, and advisors. For plan sponsors, this is an opportunity to examine pharmacy relationships with a more detailed understanding of how revenue flows through the system. For advisors, it reinforces the importance of recommending models built on structural alignment rather than rebate maximization.
At US-Rx, we will continue to monitor these developments carefully and contribute to the broader industry discussion. Pharmacy benefits represent too significant a component of healthcare spend for incentive design to remain secondary.
In the world of pharmacy benefits, the term “rebate” often gets bandied about as though it’s synonymous with savings. But in many cases, what looks like savings is not what it seems. We believe it’s time to pull back the curtain on rebates, explain their long-term impact, and highlight why our transparent, fiduciary model makes all the difference.
The Pharmacy Rebate “Shell Game”
When a drug manufacturer brings a product to market, a list price is established. A portion of that list price may later be given back to the payer via a “rebate” negotiated through the pharmacy benefit manager (PBM). This sounds straightforward: you pay a high price, you negotiate a rebate later, and you net a lower price. But in practice, the flow of money is complex, opaque, and often misaligned with the interests of the plan sponsor or the members.
For example:
A classic PBM model may negotiate rebates and keep a portion of that rebate as profit rather than passing 100 % through to the employer or plan.
The size of the rebate is often tied to the list price rather than the net effective cost or clinical value. Some drugs with high list prices generate large rebates, which may make them financially attractive to a PBM, even if those drugs are not the best value for the plan or the patient.
Because the rebate is paid after the fact, the plan or employer may still have paid or been exposed to the full list price upfront and borne the risk of that higher cost.
In short, rebates can become part of a shell game; the terminology makes it sound like you saved money, but unless the structure is transparent and aligned to your interests, you may not realize the benefit you expect.
The Long-Term Impact of Pharmacy Rebate Models
The misalignment created by rebate-centric models has several long‐term implications for employers, plan sponsors, and members:
Higher list prices – Because rebates are tied to list price, manufacturers have an incentive to set or maintain high list prices to generate larger rebate potential. PBMs may favor drugs with big rebates because their revenue depends in part on chasing those rebates. Analysts have flagged how this “chase the rebate” incentive can drive drug prices.
Formulary distortions – If drug placement on a formulary is influenced by rebate size rather than clinical value or lowest net cost, plans may end up covering higher‐cost alternatives. That means increased employer spend and possibly higher out-of-pocket costs or less-optimal therapy for the member.
Incentivized high-cost utilization – When plan sponsors or advisors use traditional “rebate spreadsheets” to compare PBMs and focus on the highest rebate guarantees, they unintentionally reinforce this dynamic. Choosing a PBM based on the largest rebate promise means the PBM must manage utilization toward the highest-cost drugs, since those are the products that generate the largest rebate checks. Over time, this approach not only distorts formulary design but also entrenches high-cost utilization patterns that inflate overall spend and undermine true savings.
Delayed benefit to the plan sponsor – Because rebates are retrospective, there is a lag time, and in some models, the plan sponsor may never clearly see or receive the full rebate value or understand how it was retained or split.
Transparency and fiduciary risk – Plan sponsors have fiduciary responsibilities (especially for self-funded plans under ERISA). When rebates, fees, dispensing profits, and other revenue streams are opaque, the plan may be at risk of hidden costs or conflicts of interest.
Unsustainable cost curves – If the model encourages high list prices and large rebates, the baseline cost of drugs grows, putting long‐term pressure on premiums, benefit design, member cost share, and employer budgets.
In essence, when rebates are treated as a “win” without drilling into the mechanics, you may be celebrating a gain while missing underlying structural issues that will catch up later.
How US-Rx Care’s Transparent Model Fixes the Problem
US-Rx Care’s model is built around transparency, alignment, and long‐term value. Here’s how we ensure rebates aren’t hiding costs, but instead support cost-effective outcomes:
Fiduciary alignment and flat fee contracting: We operate as a fiduciary PBM; our model is structured so that the plan sponsor’s interests come first. We don’t retain hidden rebates or manipulate margins to our advantage.
No conflicts of interest: Unlike traditional PBM models that may have opaque revenue flows, our contract is built on the principle of no hidden profits, no spread pricing, no rebate retention, just aligned savings.
Clinical-driven formulary and utilization design: We don’t let rebate size drive decisions; we let clinical value, efficacy, and net cost drive decisions.
Full transparency in reporting: Plans get auditable, clear reporting so they know exactly what they’re paying, what’s being reimbursed, and how savings are flowing.
Sustainable savings: Because we fix the misaligned incentive structure, we don’t just push short-term gains; we build models that control drug spend in the long run, protect against inflationary pricing, and align member care with cost value.
For employer groups, health plans, and benefits advisors, this means a model where the word “rebate” is no longer the source of confusion or hidden costs, but simply one part of a clearly defined value chain.
Key takeaways for Benefits Advisors and Plan Sponsors
Rebates don’t always equal savings. They often mask higher costs and misaligned incentives. Plan sponsors should dig deeper by asking who keeps the rebate, how list prices are affected, and whether rebate structures truly align with their fiduciary duty.
Transparency is the key to real cost control. PBM contracts should clearly define what revenue the PBM retains and how savings are passed through. Focus on net cost, not gross price minus rebate, and evaluate whether drug choices are driven by clinical value or rebate size. In the long run, rebate-heavy models inflate prices and erode savings. A transparent, fiduciary-aligned PBM ensures every dollar saved genuinely benefits the plan and its members.
A Better Way Forward: Pharmacy Transparency That Delivers Real Savings
If you’re tired of rebate gimmicks, hidden markups, and opaque PBM models, it’s time for a refresh. Let’s talk about how US-Rx Care’s fiduciary-based, transparent pharmacy benefit model can help you eliminate waste, control costs, and improve member outcomes without sacrificing care. Connect with us today at usrxcare.com/contact.
At US-Rx Care, we believe that healthcare should work for those who fund it and those who rely on it—not the middlemen. As pharmacy costs spiral and traditional PBM models continue to fall short, health plans have a powerful opportunity: to take the lead in reshaping the future of pharmacy benefits.
The landscape is changing. Now is the moment for bold decisions, clear accountability, and smarter pharmacy benefit strategies that put members and plan sponsors first.
Pharmacy Benefits at a Crossroads
Health plans are facing increasing pressure to rein in prescription costs while delivering better outcomes. But the playbook has changed. Here are four key trends defining the future of PBMs—and why health plans are best positioned to drive meaningful change:
Transparency Isn’t a Perk. It’s a Requirement
Gone are the days of complex contracts and black-box pricing. Today’s employers and plan sponsors demand clarity—and they deserve it. Traditional PBMs often profit from hidden markups, retained rebates, and misaligned incentives. That model is outdated and unsustainable.
Specialty Medications Are Reshaping the Cost Curve
Specialty drugs make up a small fraction of prescriptions—but they dominate total spend. Plans need more than discounts. They need clinical oversight, formulary integrity, and precision strategies that ensure the plan and plan members’ interest are placed above the PBM’s.
Data Is the New Advantage
Advanced analytics are powering a new era of proactive pharmacy management. From identifying savings opportunities to reducing waste and improving adherence, data is helping health plans move from reactive to strategic.
A Fiduciary PBM Built to Serve Plans, Not Profits
US-Rx Care was founded on one guiding principle: to be a true fiduciary partner. That means no hidden revenue, no conflicts of interest, and no games with the data. Just measurable results and total alignment with the plan sponsor’s own fiduciary role.
Here’s how our model is different—and why it matters to your plan:
Flat-Fee Contracting: Transparent pricing with no hidden revenue streams or incentives.
Zero Conflicts of Interest: We don’t retain rebates, manipulate formularies, or profit from your drug spend.
Clinically Driven Optimization: Every decision we make is rooted in clinical integrity and long-term member health—not margin.
Savings That Stick: Our fiduciary model consistently reduces total pharmacy spend by 30–50%, without compromising care or access.
With US-Rx Care, you’re not just outsourcing a service—you’re gaining a fiduciary partner who shares your mission and puts your plan and plan members first, always.
Leading from the Front
Pharmacy benefit reform won’t come from the status quo. It starts with forward-thinking health plans willing to challenge conventional models and demand better for their members. The future belongs to those who take control—who ask the tough questions, push for true transparency, and demand that every dollar delivers value.
At US-Rx Care, we’re here to help you lead that charge.
If you’re ready to break away from outdated PBM models and build a pharmacy strategy that works for your members, your mission, and your margins—let’s talk fiduciary.
According to recent study by Business Group on Health and the Kaiser Family Foundation, 90% of large employers believe that the cost of employee-sponsored healthcare and pharmacy benefits will become unsustainable within the next decade.
A major contributing factor is the cost of prescription drugs, which has risen 9% annually over the past ten years. For employers, this trend has increased the cost of healthcare for plans. For employees, it translates to higher deductibles and copays.
A Reality Check
As the healthcare marketplace continues to rapidly evolve, including rising costs, employers and benefit advisors are facing growing pressure to keep costs down while continuing to provide high-quality care to employees.
When it comes to controlling the cost of prescription drugs, pharmacy Benefit Managers (PBMs) have long been at the center of this challenge, but the traditional PBM model, often driven by profits, hasn’t always been in the best interest of member care or the employer’s bottom line.
This is where the fiduciary PBM model comes into play, offering a transformative solution that not only benefits the bottom line, but also prioritizes the well-being of members.
The Big Difference the ‘F’ Word Can Make
A fiduciary PBM is a one that is legally and ethically required to put the interests of its clients above all else, including its own profits. Unlike traditional PBMs, which may have conflicts of interest and profit incentives tied to formulary decisions, pricing, or rebates, fiduciary PBMs operate with complete transparency and a member-first philosophy, focusing solely on the best interest of the employer and plan members.
This means that there are no hidden rebates or kickbacks that benefit the PBM at the expense of plan nor any profits from dispensing medications. It’s about providing the most effective and affordable medications to employees and ensuring that they get them at the lowest possible cost. This typically results in a 30%-50% reduction in plan spend per member per month (PMPM)—with no change in benefit design—and a 30% (or more) reduction in out-of-pocket cost for plan enrollees.
Why is This Alignment with Member-First Principles So Important?
The importance of a member-first approach cannot be overstated. For employers, offering a benefits plan that focuses on the health and satisfaction of employees can improve workforce productivity, reduce absenteeism, and promote overall well-being.
In the long run, that means lower healthcare costs and a more engaged population.
Cost Savings and Transparency
One of the most significant advantages of the fiduciary PBM model is the level of transparency it offers based on ERISA defined terms. Traditional PBMs and many “transparent PBMs” often have hidden fees, kickbacks from drug manufacturers, dispensing profits, and opaque pricing structures that inflate the costs for employers and members. This can result in inflated drug prices, higher premiums, and a general lack of clarity around the true cost of medications. “Transparency” is not a legal term. “Fiduciary,” as defined by ERISA and embraced by US-Rx Care, is legally binding, which is why plan fiduciary status is not accepted by traditional and transparent PBMs. It can’t be without violating its core principles inherent in those conflicted PBM models.
On the other hand, Fiduciary PBMs—like US-Rx Care—offer full transparency in pricing and reimbursement, working directly with employers to ensure the lowest possible costs for prescription drugs while maintaining high-quality care. By eliminating conflicts of interest, fiduciary PBMs also pass 100% of savings directly onto employers and members. This means that employers can expect better value from their pharmacy benefits program, and employees will benefit from lower out-of-pocket costs and better access to the medications they need.
Impacts on Future Growth
The fiduciary PBM model isn’t just about saving money in the short term—it also sets the stage for sustainable, long-term growth for both employers and their members. By maintaining transparency and focusing on cost-effective solutions, employers are able to reinvest the savings into other areas of their business, whether it’s improving employee benefits or income, enhancing health programs, or even offering more comprehensive care options.
It’s truly a win-win!
By prioritizing the long-term needs of their clients and members, fiduciary PBMs are also better equipped to navigate the evolving healthcare landscape and provide solutions that can scale with the growth of the organization. This unique future-proof approach helps employers plan for tomorrow while addressing the needs of today.
The US-Rx Care Solution
Since our founding in 2007, US-Rx Care has built our fiduciary model around the core principles of ERISA-defined transparency and conflict-free accountability in the best interest of the plan and enrollees always. With no conflicts of interest, no misaligned profit incentives, no benefit constraints, and no waste, employer groups can trust that they’re getting the best deal and best outcomes possible.
If you’re ready to make the shift toward a fiduciary PBM solution that effectively mitigates risk while offering substantial savings and better long-term outcomes, let’s talk about what US-Rx Care can deliver for you.
In the meantime, click below to see how our model helped a multi-state hospital group save more than $10 million in annual drug costs!
