FTC Investigation of PBMs: What It Means for Your Pharmacy

The Federal Trade Commission has been building a public record against the pharmacy benefit manager industry since 2022, and that record is now converting into enforcement orders. In July 2026, the FTC settled with Caremark Rx and Zinc Health Services, the second of three PBMs to settle the agency's insulin-pricing complaint, after Express Scripts settled in February 2026. For a pharmacy inside an open PBM audit, the settlements change how the industry prices and rebates drugs, not how that pharmacy's own claims get reviewed.

What the FTC's PBM Study Has Found

The FTC opened its study of the PBM industry in 2022 under its Section 6(b) authority. Its first interim staff report, published July 2024, found that the top three PBMs, CVS Health's Caremark, Cigna's Express Scripts, and UnitedHealth Group's OptumRx, processed nearly 80 percent of all U.S. prescriptions, and that PBMs reimbursed affiliated pharmacies at rates 20 to 40 times higher than the National Average Drug Acquisition Cost on the two generic cancer drugs it examined. A second interim report, published January 2025, found the Big 3 reimbursed their affiliated pharmacies at a higher rate than unaffiliated pharmacies on nearly every specialty generic drug examined, and put their combined spread-pricing income on just 51 drugs at $1.4 billion between 2017 and 2022.

The Insulin Rebate Case and the PBM Settlements

Separately, the FTC filed an administrative complaint in September 2024, under Section 5 of the FTC Act, against Caremark, Express Scripts, OptumRx, and their affiliated purchasing groups. The complaint alleges, without a finding of fact, that the three PBMs built a rebate system rewarding manufacturers for higher list prices over lower net prices, inflating insulin list prices. Express Scripts settled in February 2026. Caremark settled in July 2026, agreeing to delink its compensation from a drug's list price, pass negotiated rebates through to patients at the point of sale, stop disadvantaging lower-list-price alternatives on its drug formularies, give plan sponsors more pricing transparency, and cap patients' insulin costs through a new copay program. The proposed order runs for ten years and requires Caremark to keep its group purchasing organization, Zinc, operating in the United States. OptumRx has not reached a settlement with the FTC.

The FTC's ten-year settlement with Caremark requires it to delink its compensation from a drug's list price and pass negotiated rebates through to patients at the point of sale.

What This Does Not Change for an Open PBM Audit

These settlements address the PBM's rebate architecture and specialty generic pricing at the corporate level, a different proceeding from the claims a PBM auditor reviews on a specific lookback period. A pharmacy mid-audit still has to meet the PBM's document deadline, still has to answer a recoupment demand on the PBM's timeline, and still has to file an audit appeal within the window the audit letter sets. Pharmacies defending the claim-level issues these FTC reports describe, like the coordination-of-benefits errors or copay collection findings a PBM audit can turn up, get no pause, exception, or defense from the FTC's settlement with that same PBM. A pharmacy facing network termination from a PBM named in these cases is still subject to that PBM's termination process, not the FTC's.

Health Law Alliance's attorneys have overseen 2,000+ audits and handled 5,000+ matters, with 25+ years of experience.

Where This Could Go Next

The FTC's PBM inquiry has moved one settlement at a time, and the specialty generic report is its second interim report in the same 6(b) study, not its last. Whatever OptumRx eventually agrees to is likely to track the delinking and transparency terms the FTC already secured from Express Scripts and Caremark. None of that timeline changes an open audit's schedule. The FTC's enforcement calendar in Washington has no bearing on the document deadline a PBM sets for a specific pharmacy this month.

Why Early Legal Counsel Is Critical

It is critical that pharmacies promptly retain experienced healthcare defense counsel upon receiving a PBM audit notice, document request, or recoupment demand, regardless of what federal regulators are doing with the PBM that sent it. Early legal intervention can help structure an accurate response to the PBM's request, can help avoid admissions that narrow the pharmacy's defenses later, and can preserve the pharmacy's ability to appeal. Delaying representation until after the response deadline passes can significantly narrow these options.

How Health Law Alliance Can Help

Health Law Alliance's PBM audit defense attorneys represent pharmacies nationwide against Caremark, Express Scripts, OptumRx, and other PBM audits, independent of whatever the FTC settles with those companies. If your pharmacy has received an audit notice, a document request, or a recoupment letter, contact Health Law Alliance's PBM audit defense attorneys for a free, confidential consultation.