Express Scripts agrees to reforms in settlement with FTC

Express Scripts has agreed to make big changes in how it operates to settle a lawsuit brought by the Federal Trade Commission (FTC). These changes are necessary, the agency said, to address the pharmacy benefit manager’s practices that have driven up prices for patients and limited access to local pharmacies. Agency officials in a news release said these changes could lower patients’ out-of-pocket costs for drugs such as insulin by up to $7 billion over 10 years.

“The FTC settlement is pretty significant in terms of how it changes the way that Express Scripts will perform its services,” Theresa C. Carnegie, an attorney with Mintz that works with health plans and PBMs, said in an interview.

Under the agreement, Express Scripts, which is a part of Cigna, agreed to:

• Make sure more lower-priced medicines, including insulins, are covered across all standard formularies – and make the program that caps the monthly cost of insulin at $25 the standard available for all members;
• Make sure more members pay the lowest available cost for their medicines, whether it is the negotiated cost, their copay, or a cash discount price;
• Provide covered access to TrumpRx as part of its standard offering;
• Provide a standard offering to all plan sponsors that allows the sponsor to transition off rebate guarantees and spread pricing.
• Delink its compensation from list prices as part of its standard offering;
• Increase transparency for plan sponsors, including with drug-level reporting and disclosing payments to brokers representing plan sponsors;
• Provide community pharmacies with a new reimbursement model based on actual acquisition costs, and compensate them for other essential clinical services.
• Reshore its group purchasing organization, Ascent, from Switzerland to the United States.

In a news release, Express Scripts officials said that its new, transparent pharmacy benefits model, which was announced in October 2025, ensures members get their medicines at the lowest price. The company said this new model will lower the cost of brand-name drugs by 30%.

The FTC had sued Express Scripts, as well as CVS Caremark and Optum Rx, in September 2024, saying the PBMs and their group purchasing organizations inflated the list price of drugs, including insulin, and shifted costs to patients.

The agency’s complaint had been about the influence that PBMs have not just over the pricing of insulin but also on access, saying that the companies use their formularies to steer patients to certain drugs over others. “This case challenges their role in designing, directing, and overseeing a reimbursement system, which generates billions of dollars in rebates and fees for them while incentivizing drug manufacturers to raise (not lower) the sticker price (i.e., list price) of their drugs,” the 2024 complaint said.

The ”race for rebates,” the FTC said then, should have reduced drug costs. Instead, because patient out-of-pocket costs are tied to the prices before rebates, patient costs have increased. The commission said it had focused on insulin as the “poster child” of a broken system.

Carnegie said that Optum Rx and CVS Caremark will likely consider settling with the FTC as well. “The PBM industry has been under fire for several years now. They were already moving in this direction,” she said. “We’re seeing an evolution of the PBM service model based on kind of all of these inputs. PBMs have been little by little making changes and moving their clients to different pricing models that are more compliant with some of these laws.”

The FTC is accepting comments on the settlement for 30 days. Once processed, comments will be posted on Regulations.gov.