PBM reforms, Medicare Advantage trends, TrumpRx launch, and Express Scripts settlement highlight key shifts in drug pricing, coverage, and patient access.
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The bipartisan Consolidated Appropriations Act of 2026, passed in early February, introduces the first major federal reforms targeting pharmacy benefit managers in Medicare Part D. Set to take effect in 2028, the law bars these managers from earning compensation tied to a drug’s list price or retaining portions of manufacturer rebates. It also empowers CMS to oversee disputes and establish standards for reasonable pharmacy reimbursement and contract terms. Experts describe the changes as a significant step toward transparency and reducing hidden fees that can raise patient costs, particularly for those paying deductibles based on list prices. They caution, however, that enforcement will be critical, and similar measures may need to extend to commercial insurance to fully address pricing practices.
Meanwhile, Medicare Advantage enrollment continues to rise. A study of beneficiaries from 2008 to 2022 shows steady growth in both the US and Puerto Rico, particularly among people with disabilities and those with end-stage renal disease. In 2022, partial-year enrollment in Puerto Rico reached 84%, nearly double the US’ 48%. Across both regions, full-year enrollment lagged behind partial-year enrollment, highlighting potential plan switching and raising questions about continuity of coverage, access to care, and quality for high-need populations.
In prescription drug news, the TrumpRx online platform launched, promising cash-only access to discounted brand name medications from major pharmaceutical companies. Drugs such as Ozempic, Wegovy, and Zepbound could drop to around $350 per month, with oral therapies starting near $150. The platform will not sell medications directly and will not accept insurance, raising concerns that some patients may pay more than with existing coverage.
Other recent studies and settlements include the reinstatement of Medicare’s 3-day hospitalization rule, which modestly increased hospital stays but did not improve outcomes or reduce costs, and a landmark settlement with Express Scripts, requiring major reforms to rebate and pricing practices while projecting up to $7 billion in patient savings over 10 years.
