A federal pharmacy settlement is expected to lower out-of-pocket medication costs for many Express Scripts members. It requires the pharmacy benefit manager, or PBM, to base key patient charges on lower net costs instead of higher list prices. The Federal Trade Commission approved its final order against Express Scripts and affiliated companies on February 4, 2026. The FTC projects up to $7 billion in patient savings over 10 years, but individual results will depend on each health plan.
Official resources:
- FTC insulin/PBM case file and orders — Use this primary source to verify the official guidance.
- Direct source — Use this primary source to verify the official guidance.
Table of Contents
- What does the settlement change?
- Who is most likely to benefit?
- How will insulin coverage change?
- When should patients see lower costs?
- What should patients do?
What does the settlement change?
A PBM administers prescription-drug benefits for health plans. The FTC alleged that Express Scripts favored high-list-price, high-rebate insulin over comparable lower-list-price versions. That practice could leave some patients paying cost-sharing based on an inflated list price.
Meanwhile, rebates could reduce the drug's net cost to the PBM or health plan. Under the order, Express Scripts' standard offering must cap patient cost-sharing for covered drugs at net cost. All fully insured Cigna plans must adopt these protections.
Who is most likely to benefit?
The order most directly affects Express Scripts members whose deductibles or coinsurance are calculated from a medication's list price. These patients can otherwise pay more than the drug's net cost. For example, a member may owe a percentage of a drug's list price even when rebates substantially reduce its actual net cost.
Capping cost-sharing at net cost addresses that mismatch. The protections are not identical for every member. Health plan sponsors outside Cigna's fully insured plans may choose customized terms after providing written acknowledgment.
How will insulin coverage change?
By January 1, 2027, Express Scripts generally cannot disadvantage a lower-list-price version when the same manufacturer offers a higher-list-price version. The rule applies when the lower-priced version has an equal or lower net cost and adequate supply. Express Scripts must also offer its Patient Assurance Program when a plan sponsor adopts a covered insulin formulary.
The program promises participating insulin at a lower member cost than the plan's ordinary benefit terms, unless the sponsor opts out in writing. These requirements do not guarantee that every insulin or every patient will qualify. Coverage depends on the applicable formulary, participation rules, supply conditions and the sponsor's choices.
When should patients see lower costs?
The changes arrive in stages. The lower-list-price protections must take effect no later than January 1, 2027. By January 1, 2028, Express Scripts' standard offering must pass applicable rebates and discounts to members at the pharmacy counter.
The FTC order also prohibits spread pricing in that standard offering, subject to the customized-plan exception. Spread pricing occurs when a PBM charges a plan more for a prescription than it pays the pharmacy. Prohibiting it is intended to make pharmacy costs more transparent.
What should patients do?
This FTC resolution focuses on pharmacy-benefit changes, not a stated per-person settlement payment. The cited materials do not provide an individual claim form or a fixed cash award.
Express Scripts members can take practical steps before filling a covered prescription: The FTC projects as much as $700 million in patient savings during 2026, but that figure is a projection—not observed savings or a guaranteed reduction for each patient. Readers can monitor the FTC's insulin and PBM case file for the orders and related updates.
- Ask whether the plan calculates cost-sharing from list price or net cost.
- Check whether the plan uses Express Scripts' standard offering or customized terms.
- Ask whether the Patient Assurance Program applies to a covered insulin.
- Compare the pharmacy charge with the plan's explanation of benefits.
- Keep plan notices showing changes taking effect in 2027 or 2028.