Brad Gallagher and Linda Clark, co-leaders of Barclay Damon’s Health Care Controversies and Pharmacy Teams, had their “The First PBM Falls: What the FTC’s Express Scripts Consent Agreement Means for Pharmacies” article published in the June issue of The Advocate, the National Association of Specialty Pharmacy’s member newsletter. The article examines the Federal Trade Commission’s (FTC) landmark consent agreement with Express Scripts Inc. (ESI) and what it may signal for pharmacies, plan sponsors, and future pharmacy benefit manager enforcement. The article explains how the agreement establishes a “Standard Offering” framework intended to address formulary design, pricing transparency, rebate pass-throughs, reimbursement practices, and contracting terms for eligible independent retail community pharmacies.
Several key provisions of the agreement are highlighted in the article, including restrictions on favoring higher-list-price drugs over lower-cost alternatives, limits on patient cost-sharing tied to list prices, increased transparency obligations for plan sponsors, cost-based reimbursement requirements for certain retail community pharmacies, and enhanced compliance monitoring. While specialty pharmacies are not directly covered by the Standard Offering reimbursement structure, the article notes they may still be affected by downstream changes in formulary design, utilization management, and PBM pricing practices.
The ESI agreement is one of the most significant federal interventions into PBM business practices to date and may serve as a blueprint for future PBM settlements and enforcement actions. Pharmacies should begin evaluating their contracting strategies, documentation processes, and compliance infrastructure now as the agreement’s requirements phase in.
Click here to read the full article to learn more about the consent agreement’s practical implications for retail and specialty pharmacies and how pharmacy stakeholders can prepare for evolving PBM oversight.