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.
As employers face rapidly rising health insurance costs for their employees, industry pundits are increasingly urging benefit leaders to confront “stealth” cost drivers that quietly inflate spending year after year.
While headline issues like premium increases draw the most attention, some of the most meaningful opportunities to control costs lie in areas that are often underinvested or poorly integrated into benefit strategies.
Addiction support services
Behavioral health, and particularly substance use disorders, remains one of the most expensive and least efficiently managed areas of employer-sponsored health care.
Untreated mental health and addiction issues contribute to higher medical claims, absenteeism and lost productivity. According to the Center for Prevention and Health Services, untreated mental health concerns can cost a single organization tens of thousands of dollars annually and amount to more than $100 billion nationwide.
Despite those figures, addiction and recovery services have historically received less attention than other wellness initiatives. Inpatient treatment models can be disruptive for employees and expensive for employers, while high relapse rates have made some organizations hesitant to invest more heavily in this space.
Employer actions: As a result, employers are increasingly looking at more structured, accountable recovery programs that focus on ongoing support, medication-assisted treatment and measurable outcomes.
Improving access to specialty care
Employees may technically have coverage, but long wait times for specialists can delay treatment and worsen underlying conditions. Nationally, more than 100 million specialty referrals are issued each year, yet patients in many metropolitan areas wait more than a month to see specialists such as gastroenterologists, dermatologists or cardiologists.
When employees cannot access specialty care in a timely manner, they are more likely to rely on emergency rooms or urgent care, which drives up costs.
Employer actions: Some employers are responding by supplementing traditional plans with specialty telehealth solutions or third-party platforms that shorten wait times and improve care coordination.
Consider surveying employees to identify gaps in access and understand whether additional solutions are warranted.
Accessing plan analytics to tailor benefits
Because many organizations still design benefits based on assumptions rather than real utilization patterns, only a small share of workers report being truly satisfied with their benefits — suggesting a disconnect between what is offered and what is needed.
Employer actions: Use carrier-provided tools, if available, such as reporting dashboards, health risk assessments or plan modeling software. Review claims data at least quarterly to identify cost trends, any under- or overutilization, emerging risks or cost anomalies.
Understanding which programs are being used, where employees are falling through the cracks and which interventions are producing results allows organizations to refine benefits with greater precision and financial discipline.
The takeaway
Rising health care costs are unlikely to ease in the near term, but employers are not without options. While there are many areas that can be addressed, focusing on emerging cost-containment efforts could be a winning strategy for employers.
When people sign up for a new health insurance plan, be that an employer-sponsored plan or one purchased on the Affordable Care Act (ACA) exchange, they can often be confused about when coverage starts, what is covered and whether they have to share in the medical bills.
The Kaiser Family Foundation recently compiled a list of seven takeaways from stories about people who ended up paying large out-of-pocket expenses for medical care. Health plan enrollees should read the following to learn how they can better use their plan and avoid financial blowback.
1. Most insurance coverage doesn’t start immediately
Many new plans come with waiting periods, so it’s important to maintain continuous coverage until a new plan kicks in.
One exception: An employee can opt into a COBRA policy or purchase a plan on the ACA marketplace (healthcare.gov or a state-run plan in certain states) within 60 days of losing their job-based coverage. With COBRA, once you pay, the coverage applies retroactively, even for care received while you were temporarily uninsured.
They will also qualify for a special enrollment period on the ACA marketplace to get coverage for the rest of the year. Coverage can start the first day of the month after someone loses their employer-sponsored coverage.
2. Check coverage before checking in
Some plans come with unexpected restrictions, potentially affecting coverage for care ranging from contraception to immunizations and cancer screenings.
Enrollees should call their insurer — or, for job-based insurance, their human resources department or retiree benefits office — and ask whether there are exclusions for the care they need, including per-day or per-policy-period caps, and what they can expect to pay out-of-pocket.
3. ‘Covered’ does not mean insurance will pay
Carefully read the fine print on network gap exceptions, prior authorizations and other insurance approvals. The terms may be limited to certain doctors, services and dates.
Also, while the service may be covered, sometimes it won’t be until the deductible or out-of-pocket maximum is met.
4. Get estimates for nonemergency procedures
Before scheduling a nonemergency procedure, an enrollee may be able to shop around among different providers that offer the procedure. Request estimates in writing and if an enrollee objects to the price, they should negotiate before undergoing care.
5. Location matters
Prices can vary depending on where a patient receives care and where tests are performed. If a patient needs blood work, they should ask their doctor to send the requisition to an in-network lab.
A doctor’s office connected to a health system, for instance, may send samples to a hospital lab, which can mean higher charges if it’s not in-network.
6. When admitted, contact the billing office early
When an enrollee or a loved one has been hospitalized, it can help to speak to a billing representative if possible. Questions to ask:
Has the patient been fully admitted or are they being kept under observation status?
Has the care been determined to be “medically necessary?”
If a transfer to another facility is recommended, is the ambulance service in-network or is it possible to choose one that is?
7. Ask for a discount
Medical charges are almost always higher than what insurers would pay, and providers expect them to negotiate lower rates. Health plan enrollees can also negotiate.
Uninsured or underinsured patients may be eligible for self-pay or charity care discounts.
Applicable large employers face a familiar but unforgiving task each winter: reporting their group health coverage details to the IRS. With key ACA Affordable Care Act filing deadlines falling in early 2026, employers with 50 or more full-time equivalent employees should already be reviewing records, reconciling data and preparing required forms to avoid penalties.
ACA reporting is largely about accuracy and timing, and problems often stem from waiting too long to pull information together. Here’s how to get it right and avoid penalties.
Who must report and why
An applicable large employer, or ALE, is generally an employer that averaged at least 50 full-time employees, including full-time equivalents, during the prior calendar year. Employers that met that threshold in 2025 must comply with ACA employer shared responsibility reporting in 2026.
ALEs must report whether they offered minimum essential coverage to full-time employees and whether that coverage met affordability and minimum value standards. The IRS uses this information to determine whether an employer must pay a penalty for failing to meet these requirements and to verify employees’ eligibility for premium tax credits if they purchase their own health insurance on the ACA marketplace.
The required forms
ACA reporting for ALEs revolves around two forms:
1. Form 1095-C — This form must be furnished to each full-time employee, regardless of whether the employee enrolled in coverage. The form reports the health coverage offered, if any, for each month of the year.
2. Form 1094-C — This form is filed with the IRS and serves as a summary transmittal of all 1095-C forms. Form 1094-C aggregates employer-level data, including employee counts and whether the employer is part of an aggregated group.
Due date: Employers must file paper Forms 1094-C and 1095-C with the IRS on or before March 2 for firms eligible to file on paper and electronically on or before March 31, and no additional extensions are available. Employers that file a combined total of 10 or more information returns must file electronically.
Prepare
The most common ACA reporting issues trace back to incomplete or inconsistent data. Employers can reduce risk by preparing well in advance:
Confirm 2025 full-time and full-time equivalent counts to ensure ALE status was correctly determined.
Review payroll, time-tracking and benefits systems to ensure hours worked, eligibility and coverage offers align.
Verify employee names and Social Security numbers.
Confirm monthly employee contributions for the lowest-cost, self-only plan that provides minimum value.
Review affordability calculations using the 2026 affordability threshold of 9.96%.
Be aware that hybrid and remote work arrangements can complicate efforts to track employee hours and determine eligibility. Make sure your system accurately captures hours worked regardless of the employee’s location.
Potential penalties for noncompliance
Late, incomplete or incorrect filings can trigger penalties under Internal Revenue Code Sections 6721 and 6722 for failure to file correct information returns and failure to furnish correct payee statements. Penalties generally apply per form and can add up quickly.
Separately, inaccurate reporting can expose employers to employer shared responsibility assessments if at least one full-time employee receives a premium tax credit through a marketplace. For 2026:
The penalty is $3,340 per full-time employee, excluding the first 30 employees, if coverage was not offered to at least 95% of full-time employees and dependents.
The penalty is $5,010 per affected employee if coverage was offered but was unaffordable or failed to meet minimum value, and the employee received a premium tax credit.
Bottom line
ACA reporting is not just a new year task. Employers that reconcile data throughout the year, confirm affordability calculations and review forms before deadlines are far less likely to face penalties or IRS follow-up.
Preparation should be well underway in January. Waiting until February often leaves too little time to fix errors before the March filing deadlines arrive.
Employers are heading into what may be one of the most challenging years for managing group health costs.
The new “Trends to Watch in 2026” report by Business Group on Health (BGH) outlines developments that will shape next year’s benefits environment. Rising medical and pharmacy spending, a rapidly changing policy landscape and increased pressure for innovation may pressure employers to revisit long-standing strategies and consider new ones.
Below are six trends the report predicts will affect health plans.
1. Affordability pressures intensify
Employers project a median 9% increase in health care costs for 2026, dropping to 7.6% after plan design adjustments. These increases follow two years of costs that ran higher than expected, signaling that inflationary pressure has become a persistent challenge.
Chronic conditions, an aging workforce, higher medical and pharmacy prices and ongoing system fragmentation all contribute to the strain. As a result, employers may need to weigh short-term mitigation tactics against longer-term structural changes, including program reductions or redesigned plan approaches.
2. Emphasis on preventive care and primary care
With chronic disease remaining the top cost driver, employers are expected to “get back to basics.” That means increasing the focus on preventive care, evidence-based screenings and stronger primary care engagement.
Many organizations will also reassess well-being and chronic-condition programs to ensure they produce measurable results. Incentives or alternative plan designs that encourage screenings, primary care use or condition management may become more common as employers push to improve long-term health trends.
3. Pharmacy costs will continue to weigh
Drug spending is one of the fastest-growing costs, driven by GLP-1 drugs, gene and cell therapies and broader price inflation. Existing mitigation strategies are losing effectiveness, prompting employers to re-examine pharmacy benefit manager (PBM) relationships, transparency, contracting terms and utilization controls.
The rise of direct-to-consumer cash prices adds another layer of complexity, as employees may seek lower-cost options outside the plan. Employers will need a clear stance on whether to support or discourage such use.
4. Streamlining and tightening vendor partnerships
As a result of years of adding new programs, many employers now face fragmented, duplicative services and inconsistent data integration. In 2026, the report predicts that employers will place vendors under greater scrutiny and focus on measurable outcomes. Vendors will be expected to improve data sharing, coordinate care with other partners and demonstrate value.
5. Faster adoption of alternative plan models
To manage rising costs, employers will continue to explore new plan structures. Options such as copay-based designs, virtual-first plans, primary care-centered models and network-less structures are gaining traction.
We can help you compare these models with traditional preferred provider organization, health maintenance organization and high-deductible health plan options.
6. Shifting policy landscape adds uncertainty
PBM reforms, updated preventive care guidelines and new chronic-disease coverage policies may influence employer plan design. Potential ACA subsidy expirations and ongoing Medicaid eligibility changes could increase reliance on employer coverage.
With the 2026 midterm elections approaching, legislative action may slow while regulatory activity increases. Employers will need to monitor these developments closely to anticipate compliance obligations and communicate changes to employees.
Takeaway
If the BGH report is accurate, many employers will be looking for ways to cut costs, boost vendor accountability and explore new plan structures.
If you are interested in alternative plan models, we can help you compare them with preferred provider organization, health maintenance organization and high-deductible health plan options.
For your group health plan enrollees, finding a doctor who accepts their plan should be straightforward since each plan typically has a network of physicians available for enrollees. However, enrollees regularly learn that a doctor that is clearly listed in their health plan’s provider list is no longer in their insurance company’s network, which can result in delayed or denied care as well as higher out-of-pocket costs. Welcome to the problem of health plan “ghost networks,” or “ghost providers,” which are usually the result of outdated provider lists.
This problem can result in employee resentment about their group health plan and saddle them with higher costs if they are forced to go out of network to seek out care. Here’s what your employees need to know if they encounter a ghost provider and are unable to access a certain medical service.
What are ghost networks?
A ghost network occurs when a health plan lists health care providers in its directory who are not actually available to enrollees. These providers may have:
Retired or relocated without their listings being updated.
Stopped accepting your health plan.
Reached patient capacity and are not taking new appointments.
Outdated contact information that prevents enrollees from reaching them.
Many insurer health plan directories are outdated. A 2023 report from the Office of Inspector General found that despite a Centers for Medicare & Medicaid Services rule requiring insurers to update their directories every 90 days, errors persisted. Some incorrect listings had remained on the network list for over a year.
Health plan enrollees who rely on inaccurate provider directories may experience:
Delays in care:Finding an in-network provider can take weeks or even months, potentially delaying necessary medical treatment.
Unexpected costs: Beneficiaries who unknowingly visit an out-of-network provider may face high out-of-pocket expenses or denied claims.
Frustration and confusion: Patients may have to call multiple providers, only to be told that the doctor they are trying to see does not accept their plan.
What you can do
To help your staff avoid ghost networks, train them about the importance of veryifying information provided by their insurance company. This includes checking the provider’s acceptance of new patients, their willingness to see you and ensuring they are truly in-network for your specific plan.
They can do this by contacting the provider directly and verifying their network status and patient acceptance.
Before seeing a new doctor or specialist and to ensure that they are not charged for going out of network, health plan enrollees can start by verifying provider information by:
Accessing the provider portal: Use the insurer’s website to access their provider portal and search for specific providers you’re interested in.
Directly contact the insurer: Contact the provider directly (phone, e-mail or online contact form) to confirm their willingness to accept new patients and their in-network status for your plan.
Consult the provider directory: Double-check the accuracy of the insurer’s provider directory by verifying information like office locations, phone numbers, and acceptance of new patients.
If a health plan enrollee is confronted with an inaccurate listing, they can:
Inform the insurer and request that it be corrected.
File a grievance. If an enrollee is unable to make an appointment with a doctor listed as an in-network provider, they can ask the insurance company to help you schedule an appointment or file a grievance.
