Q3 2026 has been quite a quarter in the pharmacy benefit landscape. The FTC has wrapped up its cases and reached settlements with the Big 3 PBMs, the National Alliance of Healthcare Purchaser Coalitions released its largest survey with some interesting findings for employer-sponsored health plans, and we saw several new drug approvals across a variety of conditions worth keeping an eye on.
Here’s the quick synopsis and what it could mean for your plan:
FTC Settlements Are Now Complete:CVS Caremark finalized its settlement on July 14, making it the latest of the three major PBMs to enter under consent orders that include greater transparency, bans on spread pricing, and requirements to separate PBM compensation from list-price benchmarks, following the Express Scripts settlement and OptumRx proposed consent agreement earlier this year.
GLP-1 Coverage Continues to Evolve: This quarter, we’ve seen headlines about several well-known employers changing their approach to GLP-1 coverage. Companies like Cigna, Starbucks, and PepsiCo have pulled back, while others, like Bank of America, are adding coverage and viewing GLP-1s as an investment in their members. Additionally, Mounjaro recently received FDA approval demonstrating cardiovascular protective benefits, adding another piece to the conversation around its clinical value.
Once-Weekly Insulin Arrives: For the first time, we now have once-weekly insulin options with Awiqli from Novo Nordisk and Onswik from Eli Lilly entering the market. It will be interesting to see whether the added convenience of once-weekly dosing changes utilization behavior and how providers and patients respond to other insulin therapy options.
New Drugs, New Decisions: We continue to see more development around different ways to administer medications, giving patients more options in how they take their drugs. One example is the recently launched first oral PCSK9 inhibitor, Lipfendra, which gives patients an option beyond the existing injectable versions. Other notable approvals, including Xocova, Rasonque, and Garzulys, will also be in the queue for formulary review. Biosimilar momentum also continues, with new approvals across oncology, ophthalmology, and diabetes.
QUARTERLY PULSE: TRENDS SHAPING THE LAST 90 DAYS
Big 3 PBM Consent Orders Status Update After FTC Action
In Q1, we covered the FTC’s February settlement agreement with Express Scripts. During Q2, the FTC continued considering a potential agreement with CVS Caremark, which was announced on July 14. That made Caremark the latest of the three major PBMs to reach settlement terms, after the case involving OptumRx remains unresolved.
For employers and plan sponsors, the proposed consent orders signal greater scrutiny of PBM compensation and the financial incentives behind formulary decisions. The agreements outline additional reporting requirements and options for plan sponsors to move away from spread pricing and rebate guarantees, and they also address formulary practices that favor higher-list-price medications over lower-list-price equivalents.
What the FTC Settlements Mean
PBM compensation is being separated from drug list prices: Under the standard offering, manufacturer fees paid to the PBM and its GPOs cannot be tied to favor a higher-priced drug.
Spread pricing is being phased out: The standard offering will give plan sponsors a way to move away from spread pricing and rebate guarantees, with the settlement outlining additional requirements around the standard offering.
More rebates can reach members at the pharmacy counter:The default option requires rebates to be passed through to members at the point of sale, with member out-of-pocket costs based on the plan’s contracted rate minus applicable rebates rather than the full list price.
Lower-list-price drugs get more protection: The PBM cannot discriminate against lower-WAC versions of drugs on its standard formularies, which could make the relationship between rebates, formulary placement, and drug prices something employers will want to watch more closely.
Plan sponsors get more transparency: The settlement includes additional transparency requirements, including greater access to information that can help employers better understand their pharmacy spend and PBM arrangements.
Insulin affordability programs: CVS Caremark will be required to offer affordability programs that cap members’ out-of-pocket insulin costs when applicable, although plan sponsors can opt out. The FTC estimates the CVS Caremark settlement could result in up to $8.5 billion in savings over 10 years, along with up to another $4.5 billion in potential savings from point-of-sale rebates.
What Employers Should Do Now
Use these new requirements as a benchmark when reviewing your PBM contract. The settlements give employers another reference point for what PBM transparency and pricing practices can look like. If your current contract doesn’t provide things like clear compensation terms, limits on spread pricing, or meaningful claim-level transparency, this is a good time to take another look.
Pulse of the Purchaser: Data Access is the Difference
Each year, the National Alliance of Healthcare Purchaser Coalitions surveys employers to understand the challenges shaping healthcare benefits. Its 2026 Pulse of the Purchaser survey highlights growing cost pressures and the importance of data access in managing pharmacy benefits.
Key findings include:
Survey participation:408 employers representing 3.7 million covered lives responded, with 80% reporting they were self-insured.
Projected cost increases: Employers anticipate a 7.7% increase in healthcare costs heading into 2027, before making plan design changes.
Healthcare spending:Hospital and facility costs account for 30.5% of total healthcare spending, followed by prescription drugs at 21.1%.
Data access:While 84.5% of employers have access to aggregate vendor data, only 65.3% have complete claim-level access, and just 58.6% are permitted to audit their own files.
The survey also found that employers with full claims data access tend to use more strategies to manage their pharmacy benefits.
For employers, that visibility creates an opportunity to make more informed decisions about pharmacy spending. Claim data helps identify which prescriptions are driving costs and whether a PBM is delivering on its financial commitments.
The Big Three PBM Shift Continues
The shift away from the Big 3 PBMs, Express Scripts, CVS Caremark, and OptumRx, continues. The survey found the combined market share dropped from 63% to 54% in just one year. Smaller employers drove much of that change, but larger employers are looking at their options too. Among current Big 3 PBM clients, 56% are considering switching PBMs within the next one to three years.
There’s also a clear difference in contract transparency. One in four employers with the Big 3 as their PBM said they don’t know what’s included in their PBM contract, twice the rate compared to employers using an alternative PBM. Non-Big 3 PBM clients also reported stronger contract protections around spread pricing, formulary requirements, affiliated entities, and PBM compensation.
Employer interest in PBM reform is growing as well, with support now at 87.6%. Those with full claims data are also significantly more likely to engage in healthcare policy discussions.
The takeaway is simple: employers are paying closer attention to their PBM relationships, contracts, and the transparency behind how their pharmacy benefits are managed.
What This Means for Your Plan
The Pulse of the Purchaser data reinforces that you can’t manage what you can’t see.
Full claim-level data, independent audit rights, and transparency into how your PBM is paid give employers a clearer picture of where their pharmacy dollars are going, how much they are paying for services, and the information they need to make better decisions.
And as the PBM landscape continues to change, that transparency matters even more. Whether you’re preparing for an RFP or trying to understand your pharmacy spend, it starts with having the right data and a PBM willing to show you what’s behind it.
GLP-1 Coverage at a Crossroads
The GLP-1 landscape in Q3 2026 continues to be a balancing act between the clinical case and the cost of covering these medications. Employers are still figuring out how to manage access as the GLP-1 landscape continues to change quickly.
Bank of America has pointed to the potential long-term health benefits of these medications and is also using its size to push for lower prices. This highlights the different ways employers are approaching how they balance the cost of covering GLP-1s with the potential value they can provide to members and the plan over time.
The Pulse of the Purchaser survey adds another layer to the conversation. About 68% of employers are either already limiting GLP-1 access or considering limits to certain populations. More employers are also turning to vendor-managed GLP-1 programs to manage access and cost. Use of these programs has grown from 11% of employers in 2024 to 19% in 2025, and up to 28% in 2026.
And the financial concern is understandable. The potential population eligible for GLP-1s is also much larger when these medications are covered for weight loss. That creates a very different cost equation for employers compared with covering these drugs primarily for diabetes.
The Landscape is Still Moving
At the same time, the GLP-1 landscape is far from settled. We’re already seeing meaningful price changes beginning in 2027, with manufacturers announcing lower prices for some GLP-1 products. Those changes could improve the economics for employers, but the impact will depend on the net cost to the plan after rebates, discounts, and other pricing arrangements.
And the pipeline is worth watching, too. New GLP-1s and next-generation versions are moving through development, including drugs that may offer different dosing schedules or combinations. In other words, the GLP-1 category itself is likely to look very different over the next few years.
That creates an interesting dynamic for plan sponsors. Coverage decisions made today are being made against a market that could look materially different by 2027 and beyond.
That doesn’t necessarily mean employers should constantly change their benefit strategy, but it does mean GLP-1 coverage probably shouldn’t be a “set it and forget it” decision.
Whether an employer covers GLP-1s for diabetes only, includes them for weight loss, uses a managed program, or applies utilization management, the key is to watch market changes and understand how they affect the plan. That doesn’t necessarily mean employers should constantly change their benefit strategy, but it does mean GLP-1 coverage probably shouldn’t be a “set it and forget it” decision.
FROM THE PHARMACIST’S DESK
Mounjaro Gets a Heart Indication
On August 28, 2026, the FDA approved Mounjaro (tirzepatide) to reduce the risk of major cardiovascular events, including heart attack, stroke, and cardiovascular death, in adults with type 2 diabetes who are at high cardiovascular risk.
The approval was based on a large study of more than 13,000 people that compared Mounjaro with Trulicity, another GLP-1. Mounjaro showed an 8% lower rate of major cardiovascular events, adding another piece of clinical evidence for potential benefits of GLP-1s beyond blood sugar control.
So… what does this mean for employer plans?
Mounjaro is now the first dual GIP and GLP-1 medication with a demonstrated cardiovascular benefit. This adds another consideration when appraising Mounjaro and how GLP-1 coverage fits into the broader pharmacy benefit strategy. While this alone may not significantly change current utilization, it adds another factor for employers to consider as they evaluate these medications.
The bigger takeaway is that the GLP-1 conversation continues to evolve. These medications are no longer thought of only through the lens of diabetes or weight loss. As more evidence emerges around other health outcomes, employers will want to monitor how that may impact coverage decisions and utilization.
Once-Weekly Insulin Arrives
Once-weekly insulin is also worth keeping track of.
After more than two decades without a new type of long-acting insulin, 2026 has introduced two once-weekly options: Awiqli (insulin icodec) from Novo Nordisk and Onswik (insulin efsitora alfa) from Eli Lilly.
Awiqli launched in August at a $99 list price per package, while Onswik was approved in September with pricing still to come. Both are designed to provide similar blood sugar control to daily insulin but with the convenience of just one injection per week.
The key now is where these new options fit into the pharmacy benefit.
This creates a brand-new category for formularies, with two major manufacturers now competing in the space. As Onswik pricing becomes available, plans need to adapt to product price and positioning, including whether the convenience of weekly dosing provides enough value to change how these products are covered.
Arrive New FDA Approvals to Watch
Q3 also brought several new drug approvals that highlight some of the changes we’re seeing across the broader pharmacy landscape. While not every new drug will meaningfully impact every plan, these are a few worth keeping on the radar as they enter the market.
Xocova (ensitrelvir)was approved for preventing COVID-19 following exposure and carries a $1,400 list price for a five-day course. Because it must be started within a relatively short window after exposure, plans will want to balance appropriate utilization controls with making sure those controls don’t create unnecessary delays.
Lipfendra (enlicitide)was approved as the first oral PCSK9 medication for lowering cholesterol. With an annual list price of $3,833, it enters a market that already includes lower-cost generic options and injectable PCSK9 medications. The fact that this medication is taken by mouth, along with its lower list price, makes it worth watching as plans consider where it fits their formularies.
Rasonque (daraxonrasib)was approved for certain patients with metastatic pancreatic cancer and carries a monthly list price of $39,800. Like other high-cost oncology drugs, plans will want to keep an eye on utilization and how this new treatment fits into specialty drug management.
These are good examples of why it’s important for employer plans to stay updated on more than just the latest FDA approvals. They also show how quickly the drug market continues to evolve, from new ways of taking existing medications (like moving from injectable to oral options with PCSK9s) to the continued development of high-cost treatments for complex and specialty conditions.
Not every new drug will become a major cost driver, but understanding these trends early gives plans and brokers time to think about coverage and potential impacts before utilization starts to build.
Biosimilars Keep Moving
One biosimilar worth looking closer at is Omlyclo, an interchangeable biosimilar to Xolair. Used to treat conditions such as asthma and chronic hives, it launched in Q3 at a 15% discount to Xolair’s list price.
For plans with members on Xolair, this creates a new opportunity to introduce competition into the category and potentially lower costs. It will be worth watching how PBMs position Omlyclo on their formularies and, more importantly, what the actual net savings look like for employers.
Biosimilar competition is also continuing to gain traction in other categories. Ustekinumab (Stelara) biosimilars reached 42% market share in Q3, while adalimumab (Humira) biosimilars surpassed 80%. With significant discounts now available in several of these categories, biosimilars continue to be an important area for specialty drug savings.
And there’s more competition coming.
Three additional biosimilars were approved in Q3: Ennumo for Neulasta, Ranluspec for Lucentis, and Garzulys for Novolog. None have launched commercially as of Q3, but these products are worth watching as they move toward the market and create additional competitive opportunities.
And this is where the PBM contract matters.
Just because a lower-cost biosimilar is available doesn’t automatically mean the employer captures those savings. Formulary placement, rebates, guarantees, and pricing pass-through can all affect the actual plan cost.
As more biosimilars enter the market, plan reviews should identify whether those savings go back to the employer.
What We’re Watching at US-Rx Care
At US-Rx Care, we’re keeping a close eye on these new drugs and biosimilars. As new options become available, we’re reviewing where they may make sense within our formularies and where there may be an opportunity to improve value for our clients.
We want to ensure our formularies include appropriate treatment options while also looking for opportunities to use competition and lower-cost alternatives to help manage overall drug spend. As the market continues to change, we’ll keep evaluating new opportunities for our formularies to keep up with what’s happening.
PARTNER SPOTLIGHT: THE US-RX CARE APPROACH
Built for the Market the Data Demand
The 2026 Pulse of the Purchaser survey reinforces what US-Rx Care has believed since we started in 2007: employers need the right data and transparency to make better decisions about their healthcare costs.
It’s not just about how much you’re spending, but about seeing what you’re paying for, understanding what is driving that spend, and having the information needed to do something about it.
That’s been at the core of how we built our model from the beginning.
Fiduciary model:US-Rx Care works with the plan sponsor and its members in mind. Our pharmacy benefit decisions are focused on finding the right balance between appropriate treatment, member access, and overall plan cost.
No conflicting financial incentives: We don’t make money from spread pricing, markups, retained rebates, or pharmacy ownership. We also don’t own mail-order or specialty pharmacies that could influence where medications are filled.
100% rebate pass-through: Rebates and discounts received from manufacturers are passed back to the plan, which has been part of our model from the start,
Full claim-level transparency: Employers have access to the detailed data behind their pharmacy benefit. That means you can look beyond an aggregate report and understand which drugs are being used and what they cost before considering opportunities to make potential changes.
A focus on value: We look for opportunities to lower pharmacy spend without taking benefits away from members. That can mean optimizing formularies, evaluating new FDA-approved treatments, identifying appropriate lower-cost alternatives, or ensuring savings from biosimilars make their way back to the plan.
The pharmacy market continues to move towards greater transparency, and our job is to keep up with and explain those changes to our clients and their members.
As the market continues to evolve, we’ll continue doing what we’ve always done. We follow the data and make decisions with our clients and their members best interests in mind always.
THE CONFERENCE COLLECTION
Q3 2026: Where the US-Rx Care Team Has Been
The US-Rx Care team continued engaging with employers, consultants, and healthcare leaders across the country throughout Q3 2026. Some industry events we’ve attended:
HCAA TPA Summit (Nashville, TN | Jul 27–29)
Health Rosetta Fest (Nashville, TN | Jul 29–31)
FSHP Annual Meeting (Orlando, FL | Aug 8–10)
HCBC Conference (Houston, TX | Aug 26–27)
Q4 2026: Where to Find the US-Rx Care Team
Looking ahead, the US-Rx Care team will continue attending major industry events. We look forward to connecting with employers, advisors, and industry partners throughout the remainder of 2026.
Tradeswomen Build Nations (Houston, TX | Oct 9–11)
SIIA National Conference (Phoenix, AZ | Oct 11–13)
IFEBP Conference (New Orleans, LA | Oct 25–28)
National Alliance of Healthcare Purchaser Coalitions (Arlington, VA | Nov 16–18)
Dallas-Fort Worth Business Group on Health (Dallas, TX | Dec 2–3)
Florida Alliance for Healthcare Value (Orlando, FL | Dec 9)
Purchaser Business Group on Health Annual Summit (Nashville, TN | Dec 9–11)
COMING SOON
Details will be shared in future editions as they become available.
A small share of prescriptions can drive a massive share of pharmacy spend.
One percent of prescriptions can drive more than 40% of pharmacy costs, according to our client reports. When spend is that concentrated, a focused strategy can uncover major opportunities without creating unnecessary friction across the whole plan.
For self-funded employers, that changes where the work should happen. Instead of applying the same level of intervention across an entire plan, attention can narrow to the areas creating the greatest exposure while protecting access and continuity for everyone else.
What Does Targeted Pharmacy Spend Management Look Like?
Targeted management starts with reviewing claims data to identify high-cost prescriptions that contribute most to pharmacy spend.
From there, employers can weigh changes that could improve clinical or financial outcomes without broadly changing pharmacy benefits, such as:
High-cost specialty medications
Therapies with lower-cost, clinically appropriate alternatives
Prescriptions with specific approval criteria
Concentrated spend calls for concentrated attention.
Specialty and other high-cost therapies make up a small share of prescriptions but account for an unbalanced share of pharmacy spend, and the growth of newer high-cost treatments is raising that cost further.
A review might confirm whether a high-cost therapy meets established clinical criteria, identify a clinically appropriate alternative, or help a member access the same therapy through a more affordable channel.
For employers and brokers, this is a clear opportunity for intervention.
Clinical Review In Action
When one of our members was prescribed an ultra-high-cost therapy for a rare genetic condition with specific diagnostic requirements, US-Rx started a review immediately.
The member’s clinical history and supporting documentation determined that the established criteria for the therapy were not met. The prescribing physician agreed with the assessment, and another course of treatment was pursued.
Approximately $2.2 million in unnecessary annual plan spend was avoided through a clinical decision backed by evidence.
In another case, the opportunity came down to formulation.
A young member undergoing leukemia treatment had been prescribed a high-cost liquid medication that was also available in a clinically equivalent tablet form. US-Rx Care worked with the family and prescribing physician to confirm the member could safely transition.
The therapy continued while approximately $46,000 in avoidable annual spend was avoided.
Both cases show what targeted intervention can look like in practice. Often, small adjustments in a handful of cases reduce costs without compromising member care.
What Should A Pharmacy Review Process Cover?
A pharmacy strategy review should be able to answer a few basic questions.
Which therapies are driving the greatest financial exposure?
Are high-cost claims receiving independent clinical review?
Can members actually get support when a lower-cost option is appropriate?
Are pharmacy decisions aligned with the interests of the plan and its members?
Clinical oversight can extend beyond the claim by helping members understand available treatment or pharmacy options before cost or access becomes an issue.
Our analysis across client populations nationwide found that member out-of-pocket costs were more than 30% lower through affordability and support strategies.
For employers, that matters because plan performance and member experience are inseparable, and shortchanging one usually affects the other. We offer educational guides on PBMs for employers to help better inform plan strategies.
Over time, employers can add navigation and affordability strategies based on where claims data shows the greatest opportunities.
In one self-funded employer group, plan-paid pharmacy costs per member fell 58% over two years without changing the underlying benefit design or creating broad member disruption.
Results at that scale come from precision. When pharmacy resources are concentrated on the claims carrying the greatest clinical and financial pressure, such as unoptimized drug selection or redundant benefits, employers can pursue significant savings without interfering with the rest of the member population.
Put Pharmacy Resources Where They Can Have the Greatest Impact
High-cost therapies will continue to put pressure on self-funded plans, especially as specialty and emerging treatments become a larger share of pharmacy spend.
Targeted pharmacy spend management gives employers a way to respond with more intention, pairing clinical oversight with member-conscious support and fiduciary alignment.
See where a more targeted approach could make a difference in your plan.
PBM reform is moving from policy discussion into legislation, proposed regulation, and enforcement activity.
Recent government action has brought greater attention to how PBMs make money and whether plan sponsors have enough information to oversee those relationships. Employers and health plans are facing increasing pressure to understand the agreements underlying their pharmacy benefits, even as the regulatory landscape continues to evolve.
The momentum is meaningful, but it does not make existing PBM contracts safer by default.
New requirements may improve disclosure or place limits on certain practices. They cannot rewrite an agreement that restricts audit access, preserves conflicted revenue, or keeps important financial information beyond the plan’s reach.
That work still begins with the contract.
Reform Is Changing Expectations Before Every Detail Is Settled
The regulatory picture continued to develop throughout the second quarter of 2026. The Consolidated Appropriations Act included new PBM-related provisions, and the Department of Labor proposed a fee-disclosure rule focused on PBM compensation.
Under the proposed rule, PBMs would have to provide plan fiduciaries with more information about payments received by the PBM and its affiliated businesses. This could include compensation tied to rebates, pharmacy arrangements, administrative services, and other revenue connected to the plan’s pharmacy benefit. The proposal is intended to help fiduciaries determine whether the arrangement and its fees are reasonable under ERISA.
The Federal Trade Commission has also continued to challenge PBM practices through enforcement activity and settlements, keeping attention on business practices that may affect drug costs, pharmacy access, and competition. Together, these federal actions reflect growing interest in the financial relationships behind pharmacy benefits, not only the prices or guarantees presented to plan sponsors.
US-Rx Care tracks these policy developments in The Fiduciary Files, a quarterly newsletter created to help employers, health plans, and advisors understand how changes in PBM oversight may affect their responsibilities and pharmacy benefit strategies. The Q2 edition provides a closer look at these developments and the considerations they raise for plan fiduciaries.
Taken together, these actions are raising the bar for what plan sponsors are expected to understand about their pharmacy benefit arrangements. It is no longer enough to focus on headline figures like pharmacy discounts or rebate guarantees. Fiduciaries are increasingly expected to understand how the full arrangement operates and whether the PBM’s financial interests align with the plan.
At the same time, the framework is still taking shape. Key elements remain unsettled, and the practical impact of new rules will take time to fully emerge.
For now, employers and health plans are left with a moving target:
Proposed rules may change before finalization
Implementation timelines may extend over several years
Legal challenges could reshape or delay certain requirements
Waiting for full clarity may feel prudent. In practice, it can also mean operating under contracts that were never designed in your best interest.
Make Sure Audit Rights Work in Practice
The presence of an audit provision does not necessarily mean the plan has meaningful audit access.
Some agreements narrow the records available for review. Others restrict the auditor, limit how often an audit can occur, or exclude information held by affiliated businesses. These conditions can make it difficult to verify whether pricing and payments followed the agreement.
A workable audit provision should allow the plan to tie claims to the relevant contract terms. It should also provide access to the records needed to verify the PBM’s performance.
When reviewing audit language, plan sponsors should look closely at:
Which records and revenue sources may be examined
Whether affiliated entities are included
Who may conduct the audit
What remedies are available when discrepancies are found
Auditability should provide a practical method of verification, not simply a right that exists on paper.
Contract Restrictions Can Limit the Plan’s Options
PBM agreements often shape more than pricing. They can also determine which pharmacies, clinical programs, and outside solutions the plan may use.
Required use of a PBM-owned mail or specialty pharmacy may create another source of revenue for the PBM directing the prescription. Restrictions on independent programs can also prevent the plan from pursuing a lower-cost or more appropriate option.
These provisions deserve attention because they affect the plan’s ability to act after the contract is signed. A plan sponsor may identify a better approach but discover that the agreement prevents its implementation. In that situation, more information does not produce more control.
The contract should preserve enough authority for the plan to evaluate alternatives and make decisions based on the interests of the plan and its members.
Fiduciary Governance Creates a More Durable Standard
A PBM contract may remain in place through several rounds of legislative debate and regulatory change. The plan’s responsibility to oversee that agreement continues throughout the full term.
Fiduciary governance provides a consistent standard for doing so. Rather than measuring the relationship only against the latest disclosure requirement, it considers whether the arrangement serves the best interest of the plan and its members.
That standard should guide the selection process and continue after implementation. It should influence contract negotiations, ongoing review, and the way pharmacy benefit decisions are made and documented.
US-Rx Care operates as a fiduciary pharmacy benefit manager under a legally binding obligation to act in the best interest of the plan and its members, fully conflict free. Its compensation does not depend on spread pricing or retained manufacturer revenue, and it does not own pharmacies that could benefit from dispensing decisions.
The result is a model built to support the plan’s interests rather than profit from higher pharmacy costs.
Build the Contract for the Environment Ahead
PBM reform is moving, but no employer or health plan can predict exactly where it will lead. Buyers can still make informed decisions about the agreements they enter today.
A stronger contract should include the following elements:
A full and transparent view of PBM compensation, with the ability to verify how and where revenue is generated
Clear audit and reporting rights that allow the plan to validate pricing, rebates, and affiliated entity payments
No terms that protect affiliated revenue streams at the expense of the plan’s financial outcomes
Sufficient flexibility for the plan to act when a better clinical or cost-effective option becomes available
Alignment with the fiduciary responsibilities the plan sponsor is required to uphold For a deeper discussion of recent legislative and regulatory activity, watch US-Rx Care’s PBM reform webinar.
Reform may continue changing the requirements surrounding pharmacy benefits. Employers and health plans do not need to wait to ensure complete fiduciary alignment with their pharmacy benefit manager.
Q2 2026 is confirming what Q1 set in motion, with traditional PBM models continuing to face significant regulatory pressure. All three major PBMs have now reached or moved toward settlement agreements with the FTC, a new oral GLP-1 has hit the market joining oral Wegovy, and the Stelara biosimilar trend is creating the next big specialty drug savings opportunity. Here’s what happened and what it means for your plan:
The Big 3 PBMs Now Settling with the FTC: Following Express Scripts’ February settlement, CVS Caremark reached a proposed settlement on March 23, 2026, and OptumRx reached a tentative agreement in June. The proposed agreements are expected to follow the direction established by the Express Scripts settlement, including delinked compensation, net-price benefit designs, formulary reform favoring lower-WAC alternatives, and enhanced transparency reporting.
FDA Approves Foundayo (orforglipron) on April 1, 2026: Eli Lilly’s oral GLP-1 became the first non-peptide GLP-1 pill approved for weight management. Unlike oral Wegovy, Foundayo can be taken any time of day without food or water restrictions, removing a significant adherence barrier. Self-pay pricing starts at $149 for the lowest starting dose through direct-to-consumer channels (e.g., TrumpRx, LillyDirect).
Ustekinumab Biosimilar Trending: Eight biosimilars for Stelara (ustekinumab) are now on the market at discounts of 80–90% off Stelara’s list price. With Stelara generating over $10 billion in annual sales, this represents one of the largest specialty drug savings opportunities available to employer plans today.
CAA 2026 Implementation Timelines Clarified: Most commercial market reforms take effect for plan years beginning January 1, 2029. Employers have a defined window to prepare but should not delay contract reviews.
DOL Proposed Rule Comment Period Closed April 15, 2026: The Department of Labor extended comments on its PBM disclosure rule to April 15. A final rule could be issued later in 2026. Employers should prepare for an applicability date as early as plan years beginning July 2028.
Bottom Line for Plan Sponsors
The PBM landscape continues to evolve rapidly. With all three major PBMs now moving toward settlement agreements focused on greater transparency and compensation models less tied to drug prices, plan sponsors should be proactively evaluating their current PBM arrangements rather than waiting for future regulatory deadlines.
At the same time, the arrival of new oral GLP-1 therapies and an expanding wave of high-value biosimilars presents immediate opportunities to optimize formularies and reduce pharmacy spend. Employers that assess these developments now may be well positioned to capture meaningful savings while continuing to support quality patient care.
Quarterly Pulse: Trends Shaping the Next 90 Days
The Big Three Sweep: Major PBMs Move Toward FTC Settlements
In our Q1 edition, we covered the FTC’s landmark settlement with Express Scripts in detail. Since then, the remaining two PBMs of the “Big 3” have followed suit, advancing the FTC’s sweeping enforcement action against the PBM industry.
On March 23, CVS Caremark and the FTC agreed to pause the ongoing case while a proposed settlement is reviewed. While the terms have not yet been publicly disclosed, reports indicate the agreement is expected to mirror the Express Scripts settlement, with provisions focused on net-price benefit designs, transparent PBM compensation, formulary reforms, and increased reporting requirements.
In June, OptumRx and FTC staff reached a tentative agreement, subject to Commission review, making OptumRx the final member of the “Big Three” to move toward settlement. Although details of the agreement have not been released, the proposal has been approved by FTC staff. OptumRx stated that it will continue working with regulators while remaining focused on improving patient access to care.
With all three PBMs now moving toward settlement, the planned summer evidentiary hearing has effectively been put on hold. In practical terms, reforms that were first applied only to Express Scripts are now likely to become standard requirements across the PBM industry.
What This Means for Employers
Regardless of which PBM a plan uses, the overall direction is now clear. Compensation structures that are delinked from drug prices, pass-through rebate models, net-price-based cost sharing, and more detailed drug-level transparency reporting are becoming the new PBM standard.
The question is no longer whether these changes will occur, but how quickly each PBM will adopt them.
For plans already aligned with a fiduciary-focused PBM model, these developments largely reinforce practices already in place. For those under traditional PBM contracts, the settlement trend creates both urgency and added leverage to revisit and renegotiate terms.
Foundayo Arrives: The GLP-1 Market Gets More Competitive
On April 1, 2026, the FDA approved Eli Lilly’s Foundayo (orforglipron), a once-daily oral GLP-1 for chronic weight management. Foundayo is significant for employers for several reasons:
No Food or Water Restrictions: Unlike oral Wegovy, which requires fasting and specific water intake, Foundayo can be taken any time of day with or without food. This is a meaningful adherence advantage for working adults.
Aggressive Pricing: Lilly launched with self-pay pricing starting at $149 per month for the lowest starting dose through direct-to-consumer channels (e.g., TrumpRx, LillyDirect) and commercial copay assistance as low as $25 per month.
Clinical Results: The ATTAIN program showed dose-dependent weight loss of 7.5–11.2% at 72 weeks in patients without diabetes, with improvements in blood pressure, lipids, and waist circumference. In patients with type 2 diabetes, weight reductions of 5.1–9.6% were observed alongside significant HbA1c improvements.
With oral Wegovy (launched January 2026) and Foundayo now both available, employers face an increasingly competitive GLP-1 landscape. This competition should eventually exert downward pressure on pricing, though near-term demand growth is offsetting those gains.
GLP-1 Coverage Pressure Continues
Employer coverage of GLP-1s for weight loss continues to be a major point of tension in pharmacy benefit design. Approaches are increasingly diverging, with some employers expanding access, viewing these drugs as a long-term health investment, while others are tightening eligibility or scaling back coverage due to rapid cost growth and sustained utilization pressure.
Recent developments highlight this shift in real time. Most notably, Cigna announced it will end coverage of GLP-1 medications for weight loss under its own employee health plans beginning July 1, 2026, citing cost sustainability concerns and the availability of alternative weight management approaches. The change applies only to its internal workforce and not to external employer clients, but it signals broader payer pressure on this category.
Industry-wide, momentum is mixed but increasingly cautious:
Surveys show roughly 50%–67% of large employers currently cover GLP-1s for weight loss, depending on employer size and definition of coverage.
However, ~10% of employers currently offering coverage are planning to eliminate it by 2027, while others are adding stricter utilization controls such as BMI thresholds, step therapy, or lifetime limits.
At the same time, some large employers continue to expand access, particularly those focused on long-term cardiometabolic risk reduction and productivity gains.
Other key dynamics include:
Direct-to-Consumer Pricing Creates Confusion: Both Novo Nordisk and Lilly now offer GLP-1s at $149–$500 per month through their own channels and TrumpRx, while employer plans may charge higher copays tied to list prices. Members notice the gap.
Formulary Competition: CVS Caremark excluded Zepbound starting July 1, while other PBMs continue to offer access to both Zepbound and Wegovy. Foundayo’s arrival adds another option for formulary negotiations.
Weight Regain Data Informs PA Design: Evidence continues to show substantial weight regain after GLP-1 treatment is discontinued, reinforcing the importance of designing coverage criteria around long-term clinical management rather than short-term use alone.
Reform Implementation: What’s Coming and When
With the regulatory and legislative framework largely established, the focus is shifting from what will change to how quickly the market will adapt. A series of federal actions, FTC-related settlements, and proposed rules collectively set a clearer operating direction for PBMs and employer plans.
Key themes employers should monitor include:
Delinked PBM compensation models emerging through FTC settlement activity, including agreements involving major PBMs such as Express Scripts, CVS Caremark, and OptumRx, with a focus on reducing ties between reimbursement and drug list prices.
Net-cost and pass-through benefit design requirements, reinforcing how savings are calculated and shared across payers and PBMs.
Expanded transparency and reporting expectations, including drug-level rebate disclosure, pricing visibility, and enhanced audit rights under emerging federal frameworks.
Commercial market reforms under the CAA 2026 framework beginning in 2029, which are expected to formalize stronger disclosure, auditability, and PBM accountability standards in employer-sponsored plans.
ERISA/DOL PBM disclosure rulemaking, which could further standardize employer-level visibility into PBM compensation and pricing structures once finalized.
While implementation timing varies by program, these changes collectively signal a multi-year transition toward more transparent, net-cost–driven PBM models. For employers with PBM contracts renewing in the near term, the practical implication is that contract terms should already be evaluated against the direction of these emerging requirements.
Action Items for Plan Fiduciaries
As PBM reforms continue to take shape, employers should review their current contracts and transparency provisions to ensure they align with emerging industry standards. Particular attention should be given to understanding all sources of PBM compensation, including rebates, spread pricing, manufacturer payments, and affiliated revenue streams, as well as the potential impact of a broader shift toward more transparent, fee-based compensation models. Employers that proactively evaluate these areas will be better positioned during future contract negotiations and renewals.
From the Pharmacist’s Desk
One Drug Class to Watch: Ustekinumab Biosimilars
The ustekinumab (Stelara) biosimilar market has reached a pivotal point for employers and health plans. Following years of limited competition, Stelara now faces multiple FDA-approved biosimilars, several of which are available at discounts of 80–90% compared to the reference product.
Wezlana (Amgen)
Selarsdi (Teva/Alvotech)
Pyzchiva (Sandoz/Samsung Bioepis)
Yesintek (Biocon Biologics)
Steqeyma (Celltrion)
Otulfi (Fresenius Kabi)
Imuldosa (Accord)
Starjemza (Hikma)
With Stelara generating more than $10 billion in annual sales, the growing adoption of lower-cost biosimilars presents a significant opportunity to reduce specialty drug spending while maintaining comparable clinical outcomes.
Why This Matters for Plan Spend
Stelara is one of the highest-cost specialty drugs on most employer formularies, with a WAC exceeding $25,000 per eight-week treatment cycle for the 90 mg dose. For a plan with even a handful of members on ustekinumab, transitioning to a biosimilar at 80–90% off WAC can generate six-figures of annual savings per member.
However, the same PBM dynamics that slowed adalimumab biosimilar adoption are at play here. PBMs with co-branded or affiliated biosimilar strategies may steer volume to their own products rather than the lowest-cost option. The FTC settlements should help address this over time by prohibiting formulary designs that disadvantage lower-cost alternatives, but employers should proactively ensure their formulary is optimized.
Bottom Line for Plan Sponsors
Plan sponsors should evaluate ustekinumab biosimilars based on net cost, clinical equivalence, and member access, not PBM financial incentives. Employers, particularly those working with traditional PBMs, should ensure formulary decisions are driven by plan value rather than rebate arrangements or affiliated product strategies.
For new-to-therapy patients, biosimilar-first approaches are increasingly becoming the standard. For existing patients, transitions should be coordinated with prescribers to maintain continuity of care and minimize treatment disruption.
Oral GLP-1s: Comparing the Options
With both oral Wegovy and Foundayo now available, plan sponsors and clinical teams need to understand the practical differences between these therapies to inform formulary decisions and prior authorization criteria.
Oral Wegovy (semaglutide): Once-daily tablet. Must be taken on an empty stomach with no more than 4 oz of water, then no food or drink for 30 minutes. Average weight loss of approximately 16.6% in clinical trials. Launched January 2026.
Foundayo (orforglipron): Once-daily tablet. Can be taken any time of day, with or without food or water. Average weight loss of 7.5–11.2% (dose-dependent) at 72 weeks. Higher discontinuation rates (8.7–9.7% vs. 4.5–4.9% for oral semaglutide). Stores at room temperature. Approved April 2026.
From a formulary perspective, the two products offer different value propositions. For most employer plans, the right approach is clinical criteria that allow prescriber discretion based on individual patient factors, with prior authorization ensuring appropriate utilization regardless of which product is selected.
Partner Spotlight: Transparency in Action
Positioned for the New Regulatory Reality
US-Rx Care has operated as a fiduciary PBM since its founding in 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.
The developments of Q1 and Q2 2026 have reinforced the value of that model. When all three major PBMs are being required by federal regulators to adopt practices US-Rx Care has always delivered, delinked compensation, 100% rebate pass-through, full transparency reporting, and no spread pricing, the question for plan sponsors is simple: why wait for regulatory enforcement when you can work with a partner that was built this way from the start?
The Conference Collection
Q2 2026 US-Rx Care Pulse
The US-Rx Care team has continued engaging with employers, consultants, and healthcare leaders across the country throughout Q2 2026. Some industry events we’ve attended:
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 8–11)
National Alliance of Healthcare Purchaser Coalitions Summit (St. Louis, MO | Jun 8–9)
NABIP Annual Convention (Atlantic City, NJ | Jun 27–30)
Q3 2026: Where You’ll Find the US-Rx Care Team
Looking ahead, the US-Rx Care team will continue its presence at major industry events. We look forward to connecting with employers, advisors, and industry partners throughout the summer and fall.
HCAA TPA Summit (Nashville, TN | Jul 27–29)
Health Rosetta Fest (Nashville, TN | Jul 29–31)
FSHP (Orlando, FL | Aug 8–10)
HCBC (Houston, TX | Aug 26–27)
Tradeswomen Build Nations (Chicago, IL | Sep 19–21)
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, the goal is to help 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 for plan sponsors.
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.
