The Fiduciary Files

What Matters Now: Highlights from Q1

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.

 

Partner Spotlight: Transparency in Action

Why Fiduciary Alignment Matters More Than Ever

As the FTC, DOL, and Congress push for more transparency and accountability from PBMs, the difference between a traditional PBM and a fiduciary PBM has never mattered more for employers.

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:

• Allied PBM Conference (Las Vegas, NV | Apr 1)
• BenefitsPRO Broker Expo (Chicago, IL | Apr 28–30)
• NCBCH Annual Conference (Greensboro, NC | Apr 30–May 1)
• 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.