The first quarter of 2026 produced more consequential PBM-related activity than the prior three years combined. The White House launched a drug pricing website. The FTC settled with one of the Big Three PBMs and is closing in on the other two. Congress passed the first meaningful federal PBM reform in history. States kept moving. None of it solves the problem — but some of it matters, and the distinctions are worth understanding.

TrumpRx: A Coupon Book with Good PR

On February 5, 2026, the Trump administration launched TrumpRx.gov, a government-hosted website that displays cash prices for 43 brand-name drugs and routes patients to manufacturer websites or pharmacy coupons to purchase them.[1] The site is powered by GoodRx technology and was built by the White House’s National Design Studio.[2]

There are real, if narrow, benefits. The administration negotiated voluntary most-favored-nation pricing agreements with five manufacturers — AstraZeneca, Eli Lilly, EMD Serono, Novo Nordisk, and Pfizer — producing genuine cash-price reductions on select drugs. GLP-1s are the most visible example: injectable Wegovy drops from a list price of $1,349 to around $349 per month for cash-paying patients.[1]

The limitations are significant and worth understanding before you get excited.

TrumpRx is a cash-pay platform. Purchases don’t count toward your deductible or out-of-pocket maximum.[1] For most insured Americans on high-deductible plans, using TrumpRx could actually cost more over the course of a year than staying in their plan — you’d save at the pharmacy counter while losing ground against your annual out-of-pocket limit.

The pricing commitments are voluntary. There is no statute, no penalty, and no enforcement mechanism if a manufacturer decides to withdraw a drug or change its terms.[2]

A House Energy and Commerce Committee staff report found that for nearly half the drugs listed, the administration’s claim of “world’s lowest prices” is either misleading or outright false — including 15 drugs for which cheaper generics exist but aren’t disclosed anywhere on the site.[3] Sen. Ron Wyden put it plainly: “a glorified coupon book.“[3]

That’s not nothing. Transparency about cash prices has real value, and patients without insurance will benefit meaningfully on the drugs that are listed. But TrumpRx doesn’t touch the PBM system. It doesn’t affect formularies, rebate structures, or the roughly 80% of Americans who get their drugs through employer-sponsored insurance. It is a cash-pay tool with a government logo — useful for a narrow population, and engineered for maximum political visibility.

The FTC: Three Settlements Taking Shape

More consequential than TrumpRx is what the Federal Trade Commission has been doing with its September 2024 lawsuit against the three largest PBMs, which alleged anticompetitive rebating practices that artificially inflated insulin prices for millions of Americans.

The case is resolving through a cascade of negotiated settlements. Express Scripts settled on February 4, 2026. CVS Caremark reached a proposed settlement on March 23, 2026. OptumRx negotiations are described by the FTC as showing “significant progress” in recent court filings. Together, these actions represent the first time federal regulators have extracted binding operational commitments from the companies that control roughly 80% of commercial prescription claims. We’ll have a full breakdown of what the settlement terms actually require — and what they leave untouched — in a separate post. The short version: the FTC is effectively setting a new mandatory baseline for how PBMs must operate, and the last holdout is almost certainly going to sign.[4] [5] [6]

The Federal Legislation: Real, But Delayed

On February 3, 2026, President Trump signed H.R. 7148, the Consolidated Appropriations Act of 2026. Embedded in the government funding bill were the most significant federal PBM reforms ever enacted.[7]

The key provisions:

Compensation delinking. Starting January 1, 2028, PBMs administering Medicare Part D plans must charge flat, fair-market-value “bona fide service fees” for services actually performed — and nothing else.[8] This directly targets the incentive that rewards PBMs for preferring high-list-price drugs, since bigger rebates historically meant bigger PBM revenue.

Rebate pass-through. Manufacturer rebates must be passed fully to Part D plan sponsors rather than retained by PBMs.[7]

Any-willing pharmacy. Beginning in 2029, Medicare Part D plans must allow any pharmacy meeting standard contract terms into their networks — which should reduce PBMs’ ability to steer patients to their own affiliated pharmacies and freeze independent pharmacies out.[9]

Transparency reporting. PBMs must provide semiannual reports to employer plans detailing net drug spending, rebates, spread pricing, and benefit designs that steer patients toward PBM-affiliated pharmacies.[10] Plan sponsors also gain explicit annual audit rights.[9]

What’s missing matters as much as what passed. The compensation delinking and any-willing-pharmacy provisions apply to Medicare Part D — not to the commercial market where most working Americans get their coverage. Commercial plan reforms don’t take effect until 2029.[11] The legislation also leaves “fair market value” for bona fide service fees undefined, handing the industry a significant argument to exploit during implementation.[8] The Congressional Budget Office scores the package at $2.1 billion in deficit reduction over ten years[7] — real money, but a fraction of the value PBMs extract annually from the system.

State Action and the DOL Rule

All 50 states have now passed at least some PBM legislation.[12] The 2026 sessions are continuing that trend, with focus on transparency and licensure requirements — provisions harder for the industry to challenge in court than ownership bans or delinking mandates.

Two additional federal developments deserve a watch:

The Department of Labor published a proposed rule on January 29, 2026, implementing a Trump executive order that requires PBMs serving ERISA employer plans to disclose rebates, spread pricing, and clawback fees directly to plan fiduciaries — with expanded audit rights. The comment period closed March 31; final rulemaking is pending.[13]

Massachusetts proposed a detailed PBM reporting standard on February 3, 2026, requiring disclosure of drug pricing, rebates, spread pricing, and ownership structures — with penalties up to $25,000 per week for non-compliance.[14]

What You Can Do

If you’re uninsured or your drug isn’t covered, check TrumpRx.gov. The cash prices are real for the drugs listed. Just understand the deductible math before bypassing your plan if you have one.

Ask your employer’s benefits team whether they’re using the new CAA 2026 audit and transparency rights to scrutinize your company’s PBM contract. They now have the legal tools. The question is whether they’ll use them.

Stay informed. The OptumRx settlement, DOL final rule, and CAA implementation are all active. None of these reforms enforces itself, and the industry will work the implementation process aggressively. We’ll track each development as it unfolds.

Sources:

  1. STAT News — “What to Know About TrumpRx” (Feb. 6, 2026) — https://www.statnews.com/2026/02/05/trumprx-what-to-know-drug-prices/
  2. Fierce Pharma — “TrumpRx, Government’s Cash-Pay Drug Purchasing Tool, Has Arrived” (Feb. 6, 2026) — https://www.fiercepharma.com/pharma/trumprx-governments-cash-pay-drug-purchasing-tool-primed-launch
  3. Sen. Ron Wyden — Statement on TrumpRx Announcement, Senate Finance Committee (Feb. 6, 2026) — https://www.finance.senate.gov/ranking-members-news/wyden-statement-on-trumprx-announcement; House Energy and Commerce Committee Democratic Staff Report cited via Nextgov/FCW — “House Democrats Say TrumpRx Portal Exaggerates Prescription Discounts” (Feb. 25, 2026) — https://www.nextgov.com/digital-government/2026/02/house-democrats-say-trumprx-portal-exaggerates-prescription-discounts/411663/
  4. FTC.gov — “FTC Secures Landmark Settlement with Express Scripts” (Feb. 4, 2026) — https://www.ftc.gov/news-events/news/press-releases/2026/02/ftc-secures-landmark-settlement-express-scripts-lower-drug-costs-american-patients
  5. Mondaq/Buchanan — “CVS Caremark Settles FTC Insulin Pricing Lawsuit” (Mar. 30, 2026) — https://www.mondaq.com/unitedstates/food-and-drugs-law/1766564/cvs-caremark-settles-ftc-insulin-pricing-lawsuit-key-developments-and-industry-impact
  6. National Law Review — “Settlement Dominoes: FTC’s PBM Playbook Going Industrywide” (Mar. 3, 2026) — https://natlawreview.com/article/settlement-dominoes-ftcs-pbm-playbook-going-industrywide
  7. KFF — “What to Know About Pharmacy Benefit Managers and Federal Efforts at Regulation” (updated Feb. 9, 2026) — https://www.kff.org/other-health/what-to-know-about-pharmacy-benefit-managers-pbms-and-federal-efforts-at-regulation/
  8. Sidley Austin — “Congress Passes Significant Federal PBM Reform” (Feb. 18, 2026) — https://www.sidley.com/en/insights/newsupdates/2026/02/congress-passes-significant-federal-pharmacy-benefit-manager-reform-impacting-pharmaceutical-market
  9. Buchanan Ingersoll — “Sweeping PBM Reforms Arrive” (Feb. 12, 2026) — https://www.bipc.com/sweeping-pbm-reforms-arrive-what-the-2026-federal-legislation-means-for-pharmacies,-patients-and-employers
  10. Pharmacy Times — “PBM Reform Within 2026 Appropriations Bill Signed Into Law” — https://www.pharmacytimes.com/view/pbm-reform-within-2026-appropriations-bill-signed-into-law
  11. Epstein Becker Green — “2026 Pharmacy Benefit Manager Reform: What Employers Need to Know” (Feb. 24, 2026) — https://www.ebglaw.com/insights/publications/2026-pharmacy-benefit-manager-reform-what-employers-need-to-know
  12. NASHP — State PBM Legislation Tracker — https://nashp.org/state-tracker/state-pharmacy-benefit-manager-legislation/
  13. McDermott+ — “PBM Reform: The Intersection of Legislation and Regulations” (Feb. 5, 2026) — https://www.mcdermottplus.com/blog/regs-eggs/pbm-reform-the-intersection-of-legislation-and-regulations/
  14. Mondaq — “Massachusetts Introduces Legislation to Regulate PBMs” (Feb. 24, 2026) — https://www.mondaq.com/unitedstates/healthcare/1747274/massachusetts-introduces-legislation-to-regulate-pharmacy-benefit-managers