On 14 July 2026, the Federal Trade Commission announced a settlement with Caremark Rx, LLC and Zinc Health Services, LLC to resolve claims tied to a 2024 complaint.
That complaint alleged Caremark, OptumRx, Inc., and Express Scripts, Inc. used anticompetitive rebate schemes to artificially inflate insulin prices for patients.
The FTC’s original case accused the three pharmacy benefit managers of engaging in unfair methods of competition and unfair acts or practices in violation of the FTC Act.
Specifically, the complaint alleged that PBMs used rebate-driven formulary practices that encouraged manufacturers to compete for formulary placement based on rebate size rather than the net cost of insulin.
According to the FTC, this structure resulted in higher insulin list prices and increased out-of-pocket costs for patients across the country.
The resulting Caremark Order represents the second settlement in the FTC’s ongoing litigation, following the earlier resolution reached with Express Scripts, Inc., known as the ESI Order.
The Caremark Order broadly mirrors the ESI Order, requiring Caremark to stop preferring high-WAC drugs over lower-cost alternatives and to ensure patient cost-sharing reflects contracted amounts rather than list prices.
Caremark must also provide plans with access to TrumpRx, expand insulin affordability protections including specified copay caps, and delink manufacturer compensation from drug list prices.
Despite the close alignment between the two orders, several notable differences distinguish the Caremark settlement from the earlier ESI agreement.
Unlike the ESI Order, the Caremark Order contains express exclusions for Medicare, Medicaid, and Exchange plans, effectively confining its key requirements to Caremark’s commercial pharmacy benefit business.
The Caremark Order also includes protections for hub pharmacy arrangements, limiting Caremark’s ability to restrict relationships between hub pharmacies and pharmacy hub service providers, a provision absent from the ESI Order.
The two orders also diverge on how patient cost-sharing amounts are calculated, with the Caremark Order basing calculations on the “Client Contracted Amount” less applicable rebates, rather than the Net Unit Cost framework used in the ESI Order.
On TrumpRx pricing, the Caremark Order conditions the requirement on drugs purchased through the platform and adds a carve-out where plan sponsors may opt out based on sincerely held religious beliefs or moral convictions.
Unlike the ESI Order’s general insulin cost cap, the Caremark Order imposes specific copay dollar amount caps based on the days’ supply of insulin provided to patients.
The Caremark Order also expressly permits Caremark to continue offering its TrueCost program and certain per-member-per-month net cost guarantees, provided those arrangements otherwise comply with the order.
With settlements now in place for both Caremark and Express Scripts, regulatory attention shifts squarely to OptumRx, Inc., the lone remaining respondent in the FTC’s 2024 complaint.