Understanding the Restructure of US Pharmacy Benefits Amid Reform, Regulatory Action

Historically, pharmacy benefit managers (PBMs) relied heavily on rebate-driven formulary placements, leading to the artificial inflation of drug prices, according to many experts. Rather than benefiting employers or employees, this economic model grew increasingly opaque behind the scenes.

Now, a recent Federal Trade Commission (FTC) settlement with CVS Caremark, alongside a previous agreement with Express Scripts, is establishing a new industry-wide compliance framework for transparency.

These remedies align with legislative mandates under the 2026 Consolidated Appropriations Act, aiming to prevent these unfair methods of competition from continuing. The regulatory pressure forces the market to move beyond mere “transparency” talk to actual pricing clarity, fair medication access, and cost-plus reimbursement structures.

In this week’s episode of the Over the Counter podcast, Rae McMahan, senior vice president of payor solutions at Prescryptive, shares her perspectives on the recent settlement and what the collection of actions means for prescription drug access going forward.

She emphasizes that pharmacies must proactively adapt to these new contracting standards and advocate for specialized hub-type models that guide patients through expensive, individualized therapies.

To hear McMahan break down the FTC settlement, the shift toward cost-plus reimbursement, and how independent pharmacies can survive this evolving landscape, listen to the full episode above.

Stay tuned for weekly podcast episodes of Over the Counter powered by Drug Topics. Check out our most recent episode with Duane Jones, BS Pharm, who discussed the current state of pain management in the US and how initiatives like the Johns Hopkins Perioperative Pain Program are correcting systemic mistakes that have led to the pronounced effects of the opioid epidemic.