A PBM (pharmacy benefit manager) is a middleman that manages prescription drug benefits for insurers, employers and government plans: they negotiate prices and rebates with drug manufacturers, design formularies (which drugs are covered and how), set pharmacy reimbursement and patient cost‑sharing rules, and run utilization‑management programs—functions that directly influence both list and net drug prices and patients’ out‑of‑pocket costs.
The FTC alleged Express Scripts used “preferencing” and rebate practices that incentivized manufacturers to raise list (WAC) prices and compete on large rebates rather than lower net prices; the PBM allegedly preferenced high‑list‑price versions over identical low‑list‑price versions, retained portions of inflated rebates, and thereby raised patients’ out‑of‑pocket costs that are tied to list prices.
Under the proposed consent order Express Scripts must adopt numerous behavioral and structural changes (no preferencing of high‑WAC versions on standard formularies; offer a standard plan option that bases members’ out‑of‑pocket costs on net rather than list price; delink manufacturer compensation from list prices; allow plan sponsors to transition off rebate guarantees and spread pricing; increase drug‑level transparency and disclose broker payments; move retail pharmacy reimbursement toward a cost‑plus (acquisition cost + dispensing fee) model; provide Patient Assurance Program insulin benefits to members unless a sponsor opts out; reshore its Ascent GPO to the U.S. The FTC estimates up to $7 billion in patient savings over 10 years. The public comment period is 30 days; Reuters reports the agreement runs 10 years. The FTC press release does not report a direct cash fine.
Once finalized the FTC consent order will have the force of law and the agency will enforce it; Reuters reports an independent monitor will oversee Express Scripts’ compliance for three years. The consent package is subject to a 30‑day public comment period before final issuance; material noncompliance can prompt further FTC enforcement.
Timing depends on plan sponsors adopting Express Scripts’ new standard offerings and on the consent order being finalized. Some patients could see lower out‑of‑pocket costs quickly if their employer/plan switches to the net‑price standard or opens Patient Assurance Program access; broader, economy‑wide effects are expected over years (the FTC estimates up to $7 billion in savings over 10 years).
Yes. The FTC described the deal as “landmark” and it grew out of the agency’s broader enforcement campaign (its 2024 suit named Express Scripts, Optum and Caremark). The consent order creates an enforceable template of reforms (delinking rebates, net‑price cost‑sharing, greater transparency, cost‑plus pharmacy payments, reshoring Ascent) that the FTC can cite or seek in future PBM actions; separate litigation against other PBMs continues.