The FTC’s PBM enforcement actions gave us a glimpse behind the curtain; it’s time to let the light in.

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The Federal Trade Commission has pulled back the curtain on the historically opaque pharmacy benefit manager industry. The FTC’s settlements with CVS Caremark and Express Scripts, with an OptumRx agreement expected, represent a major federal intervention into predatory PBM practices.

However, as history shows, when PBMs face scrutiny, they adapt quicker than regulation can touch them – changing structures, shifting strategies, and shedding their skin to preserve the same underlying incentives. The FTC must rigorously monitor and enforce compliance of these agreements to ensure meaningful reform.

What the Settlements Change (And What They Don't).

The FTC settlements seek to change several PBM practices for their “standard offering to plan sponsors” by requiring point-of-sale rebate pass-through options, prohibiting compensation tied to a medicine’s list price and ensuring eligible TrumpRx purchases count toward patients’ deductibles and out-of-pocket costs.

However, these middlemen are well documented to preemptively adapt their business practices to minimize the reach reforms can have on their business. The reality is, the settlement agreements are unlikely to fundamentally alter the dominance of the “Big Three” PBMs, and while the standard offering will change, there is a strong potential no other offerings will and employers can still be steered into other contract arrangements where many of the same financial incentives for PBMs will likely remain. We can also anticipate that PBMs will be under pressure to make up for lost compensation across their book of business by collecting additional revenues from non-standard plans.

The industry’s own executives have made clear they believe they can adapt.

The PBMs' Message to Investors: Regulation is Coming, We’re Not Worried.

PBM executives reassured investors that regulatory changes would have little impact on profitability or long-term growth.

Cigna President and Chief Operating Officer Brian Evanko said the FTC agreement “will not impact our ’27 financial outlook,” adding that the company expected “a comparable level of profitability between the legacy model and the new model.”

“We have known these changes were coming,” CEO David Joyner told investors, adding that the company had already been preparing for new payment models and greater scrutiny.

Meanwhile, both CVS and Cigna reaffirmed and raised earnings guidance following the settlements.

A Step in the Right Direction, More Work Remains.

While the FTC is working on enforcement, policymakers have an opportunity to build on that momentum, throw open the curtain, and address not just yesterday's practices, but tomorrow's playbook.

Eliza Maciag

Eliza Maciag is a senior manager on PhRMA’s Public Affairs team, focusing on 340B, PBMs and the cost and value of medicines. Prior to joining PhRMA, she worked in the Strategic Communications department at the Investment Company Institute, where she led rapid response initiatives and grassroots campaigns. Eliza holds a bachelor’s degree in political science from Trinity College (CT) and a master’s degree from the Graduate School of Political Management at George Washington University.

Originally from Connecticut, Eliza is based in Washington, D.C. Outside of work, she enjoys golfing, biking, skiing and swapping book recommendations.

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