The week of February 2, 2026, marks a pivotal moment in the ongoing national effort to reform pharmacy benefit manager (PBM) practices and reduce prescription drug costs for Americans.

New laws, rules, and market shifts are coming together to make substantial changes for health plans and patients.

• The Consolidated Appropriations Act (CAA) of 2026, signed into law on February 3rd, introduces sweeping PBM transparency and accountability requirements. (For more information on this, click the blue download button on the right.)
• The Federal Trade Commission (FTC) announced on February 4th a proposed consent order with Express Scripts (ESI) targeting rebate-driven pricing models has been secured.
• On February 5th, the Trump Rx website launched, offering discounted cash-pay pricing on select brand-name medications.

In this article, we focus on the FTC’s proposed consent order, as it is likely to foreshadow similar outcomes for other pharmacy benefit managers.

FTC Settlement with Express Scripts

The Federal Trade Commission announced a landmark settlement with Express Scripts (ESI) following allegations that the PBM’s rebate‑driven formulary practices contributed to artificially inflated insulin list prices and higher out‑of‑pocket costs for patients. The settlement requires ESI to implement significant reforms aimed at increasing transparency, reducing member cost‑sharing, and shifting away from pricing models that prioritize high‑list‑price drugs.

Consent Decree Highlights

Under FTC’s proposed consent order, ESI has agreed to:

• Lower member costs: ESI must offer plan designs that base member cost‑sharing on the net cost of a drug rather than the list price, which is expected to reduce out‑of‑pocket costs, particularly for insulin.
• Enact formulary changes: ESI will no longer be permitted to prefer high‑WAC drugs over identical lower‑WAC options on standard formularies.
• Reduce Reliance on Rebates: Plan sponsors will have a new option to transition away from rebate guarantees and spread pricing models.
• Provide greater transparency: ESI will be required to provide drug‑level reporting, disclose broker compensation, and supply data needed for Transparency in Coverage compliance.
• Reform pharmacy reimbursement: ESI will shift to a more transparent reimbursement model for community pharmacies based on actual acquisition cost plus a dispensing fee.

Expected Timing

• The settlement is currently in a 30‑day public comment period.
• Once finalized, the consent order becomes legally binding and implementation begins.
• Transparency and reporting requirements typically take effect first.
• Pricing and formulary changes are likely to align with future plan‑year cycles unless the final order specifies accelerated timelines.
• Structural changes, such as reshoring ESI’s group purchasing organization, will phase in over a longer period.

Bolton will continue to track the final consent order and provide guidance on how plan sponsors can leverage these changes to improve affordability and transparency within their pharmacy benefits programs.

If you need help cutting waste, strengthening clinical oversight, and getting more value from every pharmacy dollar, Bolton’s Pharmacy Consulting team is ready to help. Contact us.