The Fiduciary Files

What Matters Now: Highlights from Q2

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:

• 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 8–11)
• 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.