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The Federal Trade Commission has announced what it called a "landmark settlement" with Express Scripts over insulin pricing.
The settlement resolves a lawsuit alleging that Express Scripts' conduct resulted in artificially inflated insulin drug prices, the FTC said.
Pharmacy benefit manager Express Scripts is part of Evernorth Health Services, the health services division of The Cigna Group.
The settlement was announced Wednesday, the day before Cigna announced its Q4 2025 earnings and within the same week that Congress passed a funding bill that includes PBM reform.
Express Scripts is among the country's largest PBMs, the FTC said.
The FTC had also brought enforcement actions against Caremark Rx, which is part of CVS Health and OptumRx, which is part of UnitedHealth Group.
The recent settlement resolves the FTC's lawsuit, which alleged that Express Scripts and affiliated entities artificially inflated the list price of insulin drugs by using "anticompetitive and unfair rebating practices." This impaired patients' access to lower list price products, shifting the cost of high insulin list prices to vulnerable patients, the FTC said.
WHY THIS MATTERS
The settlement requires that Express Scripts and its affiliated entities adopt changes to its business practices that increase transparency and drive down patients' out-of-pocket costs for drugs like insulin by up to $7 billion over 10 years.
The PBM is also required to bring millions of dollars in new revenue to community pharmacies each year and to advance the Trump administration's healthcare priorities. This includes providing covered access to TrumpRx as part of its standard offering.
It must also reshore its group purchasing organization Ascent from Switzerland to the United States, which will bring back to the United States more than $750 billion in purchasing activity over the duration of the order.
Under the consent order, Express Scripts and its affiliated entities have agreed to stop prioritizing its standard formularies high wholesale acquisition cost versions of a drug over identical low wholesale acquisition cost versions.
Express Scripts must provide a standard offering to its plan sponsors that ensures that members' out-of-pocket expenses will be based on the drug's net cost, rather than its artificially inflated list price.
Also, it must provide full access to its Patient Assurance Program's insulin benefits to all members when a plan sponsor adopts a formulary that includes an insulin product covered by the Patient Assurance Program.
A standard offering must be provided to all plan sponsors that allows the plan to transition off rebate guarantees and spread pricing.
Express Scripts must delink drug manufacturers' compensation from list prices as part of its standard offering.
Some of these and other conditions are now part of PBM reform that Congress passed in a minibus package this week to fund the government.
The FTC voted to accept the consent agreement for public comment by 1-0, with Commissioner Mark Meador recused. The public has 30 days to submit comments on the proposed consent agreement.
THE LARGER TREND
The FTC has alleged that PBMs created a system that artificially drives up the list prices of drugs by preferencing rebates.
The Express Scripts complaint alleges that this system pushed insulin manufacturers, among others, to compete for preferred formulary coverage based on the size of rebates off the list price rather than net price, which ultimately benefitted the PBMs, which keep a portion of the inflated rebates.
According to the FTC's complaint, the inflated list prices hurt patients whose out-of-pocket payments like copays and coinsurance are tied to the list price of the drug.
ON THE RECORD
"The FTC's settlement with Express Scripts is a clear testament to the Trump-Vance FTC's focus on lowering healthcare costs for American patients," said FTC Chairman Andrew N. Ferguson.
Email the writer: SMorse@himss.org