Analysis says pharmacy benefit managers have escaped the administration's drug pricing push

An analysis published Sept. 9, 2026 argues that the Trump administration has pressed drugmakers on pricing while taking comparatively little action against pharmacy benefit managers, the companies that negotiate prescription drug prices for employers and health plans ^[1].

The Forbes piece, by contributor Joshua P. Cohen, says the administration has described provisions in the 2026 Consolidated Appropriations Act and settlements with the Federal Trade Commission as "historic victories," but that critics see the results as weaker than what was originally promised ^[1]. It appeared about three weeks after the PBM industry pledged to display TrumpRx cash prices inside its benefit tools, a move the analysis describes as imposing no change to rebate economics ^[1][2].

PBMs negotiate prices on behalf of employers and health plans, build pharmacy networks, manage formularies, process claims and run specialty pharmacies ^[1]. The three largest — CVS Health's Caremark, Cigna's Express Scripts and UnitedHealth's Optum Rx — together control 80 percent of prescriptions in the United States, according to the analysis ^[1]. All three sit inside larger conglomerates that also own insurers, specialty pharmacies and, in some cases, provider clinics or drug manufacturers ^[1].

The FTC finalized settlements with Express Scripts and CVS Caremark this year over insulin pricing, and a third settlement with Optum Rx is likely, the analysis says ^[1]. Cohen writes that the settlements carry no monetary penalties, no admissions of misconduct or liability and no restitution fund for patients who paid inflated insulin co-payments — only a consent order with promises of better behavior and limited monitoring ^[1]. There is no federal ban on rebates or on spread pricing, the practice of charging plan sponsors more for a drug than the pharmacy is reimbursed and keeping the difference; PBMs can still spread price in Medicaid in states that permit it ^[1].

The settlements require PBMs to offer plan sponsors a "standard offering" that passes 100 percent of manufacturer rebates to patients at the pharmacy counter, but the agreements let employer plan sponsors opt out and keep older, non-transparent contracts ^[1]. The Consolidated Appropriations Act mandates 100 percent pass-through of negotiated rebates for commercial and Medicare Part D plans beginning in 2028, allows PBMs to earn itemized, flat-dollar fees instead, and from 2029 requires Part D sponsors to accept any pharmacy that meets standard contract terms ^[1]. Semiannual PBM reporting on prescription drug and spread pricing starts in 2028 ^[1]. A proposed Department of Labor rule, first drafted as an executive order in January 2026 and under review after public comments this spring, would require PBMs to disclose earnings from rebates and spread pricing to self-insured plan sponsors ^[1].

PBM leaders defend their role. UnitedHealth's OptumRx told Fortune that rebates helped eligible patients save $1.3 billion in out-of-pocket costs, and the trade group Pharmaceutical Care Management Association says PBM-owned specialty pharmacies cost less than other pharmacies ^[1]. In August 2026, PCMA and ten PBMs committed to presenting TrumpRx cash prices to patients through real-time benefit tools "when consistent with plan coverage and allowed by law," a step CMS Administrator Dr. Mehmet Oz said would give patients greater visibility into how much they pay ^[2].

Why it matters for patients

Whether a medicine is covered at all, and what it costs at the counter, is shaped by a formulary and a contract most patients never see ^[1]. The analysis argues that rebates generally do not reach patients at the point of sale, that co-insurance is often calculated on list prices rather than net prices after rebates, and that patients can pay more during the deductible phase when higher-list-price drugs are preferred ^[1].

Employer opt-outs matter too. A large employer that keeps an older contract can continue using rebates to offset overall premium costs instead of lowering point-of-sale drug prices, so two people on the same medicine could face different costs depending on who their plan sponsor is ^[1].

The analysis does not break out GLP-1 medications such as semaglutide (Ozempic, Wegovy, Rybelsus) or tirzepatide (Mounjaro, Zepbound). Whether these particular reforms would change coverage or out-of-pocket costs for those drugs specifically has not been reported ^[1].

What happens next

The 2028 rebate pass-through and reporting requirements and the 2029 pharmacy network rules are written into the Consolidated Appropriations Act ^[1]. Timing for the possible Optum Rx settlement and for a final Department of Labor disclosure rule has not been disclosed ^[1].