A Big Insulin Story Hiding in the Fine Print

Insulin is a lifeline, and the bill at pickup can land like a punchline nobody asked for. In February 2026, the Federal Trade Commission announced a proposed settlement with Express Scripts, a major pharmacy benefit manager, tied to allegations about inflated insulin list prices and rebate practices. The FTC says the deal would require changes that increase transparency and could cut what patients pay out of pocket for drugs like insulin by up to $7 billion over ten years.

This matters because the price you pay often depends on rules you never see, including which version of a drug gets preferred placement and how your cost sharing is calculated. In this blog, we’ll explain what the FTC alleged, what the proposed order would require Express Scripts to do differently, and what to ask your plan sponsor or insurer. We’ll also tell you how to submit a comment before the agreement becomes final.

Why Rebates Can Still Leave Patients Paying More

Pharmacy benefit managers (PBMs) build formularies for health plans and negotiate with drugmakers, then the rest of us meet the results at the pharmacy counter. In its 2024 case against several large PBMs, the FTC alleged that manufacturers competed for formulary access by offering larger rebates off higher list prices, with less focus on lower net prices. The agency also alleged that PBMs could steer patients toward higher list price insulin while lower list price versions were available, because higher list prices can generate larger rebates and fees.

The consumer problem shows up when your share is tied to list price, which often happens with co-insurance and during deductible periods. If rebates are paid back later, they can lower what the plan pays overall without lowering what you pay that day. That gap is why the FTC framed the insulin case as a competition issue that shifts costs onto patients who can least absorb the hit.

What the FTC Says the Express Scripts Order Would Change

The FTC says the settlement would stop Express Scripts from preferring higher cost versions of a drug over identical, lower cost versions on its standard formularies. It would also require a standard option for plan sponsors that bases members’ costs on a drug’s net cost, not its list price, aiming to reduce surprise bills tied to inflated list prices. Another structural change in the proposed order would allow sponsors to transition away from rebate guarantees and spread pricing, and unlink manufacturer compensation paid to Express Scripts from list prices.

The proposed order also leans into transparency, including drug-level reporting meant to help plan sponsors comply with federal Transparency in Coverage rules. For pharmacies, the FTC says Express Scripts would shift its standard terms toward acquisition cost + a dispensing fee + additional compensation for certain services. This model is intended to help make things clearer for community pharmacies. The FTC also says Express Scripts will move its purchasing organization from Switzerland to the United States.

What You Can Do Now and How to Weigh In

A proposed consent order isn’t final, and your plan may not change overnight; still, you can use this moment to make your opinions heard. From now until March 16, 2026, public comments on the Express Scripts consent agreement are welcomed. If you choose to leave a comment, just make sure to keep it focused on pricing and access, and leave out sensitive personal details since submissions can become public.

When you contact HR or your insurer, ask for the most recent formulary and the cost sharing language for your specific insulin. Here are a few questions worth asking your employer, insurer, or benefits administrator this month:

• Is my insulin cost based on list or net price at the counter?
   
• If a lower list price option exists, is it covered?
   
• Do we have an insulin assurance program, and can it apply before the deductible is met?
   
• How can I track formulary changes during the year?

Once the Commission issues a final consent order, it carries the force of law for future conduct, so public input now can matter. TrustDALE will keep tracking consumer-facing changes in drug pricing and coverage, so check back for updates and share this with anyone who’s tired of gambling on their next refill.

To let the FTC know your thoughts on the agreement, click here. Just remember, submissions are only open until March 16th! 

To read the comments that have already been posted, click here.