What happened
On July 14, 2026, the Federal Trade Commission announced a settlement with CVS Caremark and its group purchasing organization, Zinc Health Services, resolving the agency's insulin-rebate case. Caremark is the second of the three largest pharmacy benefit managers to settle, after Express Scripts in February. The FTC says the agreement "locks in place up to $8.5 billion in consumer savings over the next 10 years," with up to $4.5 billion in additional savings from passing rebates through at the point of sale.
The underlying complaint, filed in September 2024, alleged that the three PBMs (which together administer roughly 80% of U.S. prescriptions) had built a rebate system that favored insulin products carrying high list prices and disadvantaged lower-list-price equivalents, while patient cost-sharing was calculated off those inflated list prices.
| Date | Event |
|---|---|
| Sept 2024 | FTC administrative complaint against Caremark, Express Scripts, and Optum Rx, together with their group purchasing organizations |
| Feb 4, 2026 | Express Scripts settles: delinking compensation from list prices, formulary commitments, transparency obligations |
| Jun 12, 2026 | The Commission withdraws its case against Optum Rx from adjudication to consider a proposed consent agreement |
| Jul 14, 2026 | Caremark settles: the remedies described below |
| Pending | Optum Rx: proposed consent agreement still under consideration; terms not public |
What Caremark agreed to
The settlement is structural rather than financial. No fine, no disgorgement, no admission. The order runs to twelve substantive sections. All twelve are below.
- Formulary treatment (I). Stop disadvantaging a low-list-price version of a drug on standard formularies, where its net cost is no higher than the high-list version and it is not on the FDA shortage list.
- What members pay (II). Cap a member's out-of-pocket cost at the amount the plan was charged for that claim, less any rebate on it. That holds for every plan type, including high-deductible plans.
- TrumpRx access (III). Pass through direct-to-consumer pricing and count those payments toward deductibles and out-of-pocket maximums, if legislative or regulatory changes permit it. A plan sponsor may decline on religious or moral grounds.
- Insulin (IV). Launch a Copay Certainty Program capping member cost for participating insulins at $25, $50 or $75 depending on days' supply. It applies automatically unless the plan sponsor opts out in writing.
- Rebates and spread (V). Pass rebates through at the point of sale with no fee beyond the actual cost of pre-funding them; stop guaranteeing a fixed dollar amount of manufacturer compensation; and stop using spread pricing. TrueCost and per-member-per-month net cost guarantees remain permitted.
- Manufacturer fees (VI). Stop tying the compensation Caremark receives from drug manufacturers to list prices or list-based benchmarks.
- Reporting (VII). Give plan sponsors annual drug-level cost reporting and pharmacy claim-level reporting, the data needed for Transparency in Coverage compliance, and disclosure of the broker and consultant compensation Caremark pays or facilitates.
- Community pharmacies (VIII). Offer reimbursement at a pharmacy's actual acquisition cost plus a dispensing fee, pay separately for non-dispensing services, and admit any qualifying pharmacy willing to accept those terms.
- Hub services (IX). Stop unfairly interfering with network pharmacies' ability to work with pharmacy hub service providers.
- Promotion (X). Actively market the standard offerings (a minimum of $10 million a year for five years), disclose their availability in marketing materials and in response to every request for proposal, and not disparage them.
- The rebate GPO (XI). Keep the negotiating activities, employees and assets of its rebate group purchasing organization in the United States.
- The exception (XII). Caremark may offer a plan sponsor terms that differ from the standard offering, but only on written request, only after providing the standard offering terms, and only with a signed acknowledgment that the sponsor read and understood what it was declining. That exception does not apply to Aetna's own fully insured plans.
A compliance monitor serves for three years. The order runs for ten years, and the obligations above arrive in two waves: the first no later than January 1, 2027, the remainder by January 1, 2028.
The part that matters for plan sponsors
Caremark must offer. Caremark must allow. Caremark must make available. What the settlement does not do is rewrite any particular plan's contract.
The mechanism is a single defined package. The order requires Caremark to assemble one set of terms (it calls this the Standard Offering) and to make it available to every plan sponsor, current or potential. Almost everything the settlement requires lives inside that package. The order regulates the package. It does not regulate what any individual plan actually buys.
The FTC changed what plans are able to ask for. It did not change what any plan is getting. That second step belongs to the fiduciary.
For a self-funded employer or a Taft-Hartley fund, this is the practical consequence: a set of options is on its way that did not exist in June, and none of them will arrive automatically. Someone has to evaluate them and decide. Under ERISA, that someone is a fiduciary making a decision they should be able to document.
Each of those decisions turns on arithmetic, not philosophy. Whether point-of-sale rebate pass-through leaves a plan better off than its current rebate guarantee depends entirely on that plan's own claims, its own plan design, and its own population's utilization. Two plans with the same PBM can reach opposite answers, correctly.
Four questions a benefits committee should answer before these provisions take effect
- Our members' cost share is calculated on a price. Is it the price the plan actually paid? Section II sets the standard: a member's out-of-pocket cost capped at what the plan was charged for that claim, less any rebate on it. That explicitly includes high-deductible plans. Today those two numbers are rarely the same, because rebates arrive months later in aggregate and never touch the claim the member paid on. Standard reporting shows plan spend and member spend as separate lines; it does not put them on the same claim, net of rebate. And because deductibles front-load, the gap falls hardest early in the year, on the members least able to plan for it.
- We watch the expensive drugs, but are we overspending on generics? Attention follows unit cost, so it lands on specialty. Generic cost hides in volume: thousands of small claims, none individually notable, and no report totals them against what the drugs cost to acquire. A strong discount guarantee does not answer this: discounts are measured against list price, not against what the drug cost to buy. Published acquisition-cost benchmarks make it measurable claim by claim, at NDC level, across every channel a plan uses. Some of the gap is legitimate. Pharmacies are paid to dispense. The question is how much of it is, and whether anyone has ever checked.
- Our GLP-1 spend is the number everyone is watching. Do we know what our members are paying on it? This settlement will be read as an insulin story. Section II is not insulin-specific. It reaches every covered drug. The class where that matters most in dollars is the one already dominating pharmacy trend, where the gap between list price and net cost is widest and members on coinsurance feel it directly.
- These terms are not ours by default. How would we decide what to elect and how to measure the result? Both answers start in the same place: what our members pay now, compared with what these terms would give them. Run it before, and the comparison is the decision. Run it again after, and it is the result.
What this settlement does not mean
Six things worth being careful about
- This order is not final. It is a proposed consent order, on the public record for a 30-day comment period; the Commission's Analysis to Aid Public Comment states it will then decide whether to "withdraw, modify, or finalize the Proposed Order." The February Express Scripts order does not appear to have been finalized yet either.
- This is not a finding that any PBM broke the law. The settlement carries no admission of wrongdoing and no fine. The remedies are forward-looking.
- The case is insulin-anchored. Several remedies (formulary treatment, the pass-through option, the ability to exit rebate guarantees) reach more broadly, but this is not an economy-wide overhaul of pharmacy benefit management.
- The savings figures are FTC projections, not audited outcomes, and they describe the market in aggregate. They say nothing about what any individual plan will save.
- Optum Rx has not settled. Its case was withdrawn from adjudication on June 12, 2026 so the Commission could consider a proposed consent agreement. The terms have not been made public. Coverage describing this as a completed settlement is ahead of the record.
- The order covers commercial business only. Medicare (including employer group waiver plans), Medicaid, and Exchange plans sit outside the order's definitions.
The honest framing is narrower than the headlines and more useful: a regulator has expanded the menu that will be available to plan sponsors. Whether anything on that menu is worth ordering is a question about one plan's data.
Sources
- Federal Trade Commission, "FTC Secures Major Settlement with Caremark, Resolving Antitrust Case Against Second Drug Middleman," July 14, 2026. ftc.gov
- Federal Trade Commission, "FTC Secures Landmark Settlement with Express Scripts to Lower Drug Costs for American Patients," February 2026. ftc.gov
- Federal Trade Commission, Order Withdrawing Matter from Adjudication (Optum), June 12, 2026. ftc.gov (PDF)
- Federal Trade Commission, Caremark Rx, Zinc Health Services, et al., In the Matter of (Insulin), case page. ftc.gov