FTC Settlement with Caremark: Key Provisions for Plan Sponsors

On July 14, 2026, the Federal Trade Commission reached a settlement with Caremark, Rx, LLC. and Zinc Health Services, LLC (collectively “Caremark”). The settlement resolves the lawsuit filed by the Commission charging Caremark with engaging in unfair methods of competition and unfair acts or practices in violation of Section 5(a) of the FTC Act. A settlement was reached with Express Scripts (ESI) earlier this year and a settlement with Optum Rx is pending.

The initial complaint alleges that Caremark’s rebating practice pushed insulin manufacturers to compete for preferred formulary coverage based on the size of rebates off the list price rather than net price. The FTC claimed that this practice unfairly benefited the PBMs which retain a portion of the inflated rebates and hurt patients with copays and coinsurance that are tied to the list price.

The consent agreement includes the following concessions specific to Caremark and is effective once the FTC issues the final order after a 30-day public comment period.

Implementation Date: January 1, 2027, or when Caremark certifies all requirements have been implemented, whichever is earlier.¹

Standard Offering – Aetna Fully Insured Plans

• Caremark will enter into an agreement with Aetna for all domestic fully insured health plans of Aetna to include the following:
  • Members’ out‑of‑pocket costs for each covered drug are no higher than the contracted amount less any rebate per claim regardless of plan type (including HDHPs);
  • Members’ out-of-pocket costs will not be based on list price or any other benchmark higher than the contracted amount less any rebates;
  • Full access to programs that reduce out-of-pocket costs for members, including the Copay Certainty Program (no later than January 1, 2028) and a preferred drug list with first-dollar coverage for insulin and other preventative drugs.
• Caremark is prohibited from offering non-standard options for Aetna plans.

Standard Offering – Plan Sponsors

TrumpRx and Insulin

• TrumpRx will be included as a standard offering, subject to legal and regulatory considerations;
• Member payments made through the TrumpRx platform must be counted toward the deductible and out-of-pocket cost maximum accumulations;
• If a plan sponsor adopts a formulary that includes insulin products, Caremark must provide full access to the Copay Certainty Program including at least one participating insulin product in each of the rapid-acting, short-acting and long-acting insulin categories unless plan sponsor opts out in writing;
• Out of pocket costs for participating insulin products under the Copay Certainty Program will be capped as follows:
  • $25 for 0-34 days’ supply
  • $50 for 35-68 days’ supply
  • $75 for 69 or longer days’ supply

Rebates and Compensation

• Pass-through rebates and discounts must be provided at point of sale with no fee for providing or administering a point-of-sale rebate program other than the actual cost to pre-fund any rebate.
• No guarantees of pre-determined compensation from drug manufacturers, including rebate amounts. However, Caremark can continue to offer TrueCost and net cost guarantees using PMPM pricing if there is compliance with other standard offering provisions;
• No spread pricing;
• Compensation received by Caremark from drug manufacturers will not be based on the list price of any drug or any related benchmark.

Standard Offering – Retail Community Pharmacies

• Compensation will be based on actual acquisition cost plus a dispensing fee. Additional payments will be made for non-dispensing services.
• Retail Community Pharmacies will be required to provide Caremark with quarterly data to validate acquisition costs. If validation data is unavailable, Caremark will disclose its acquisition cost methodology to the Retail Community Pharmacy.

Non-Standard Offerings

• Caremark must obtain an acknowledgement from plan sponsors that agree to terms that differ from the standard offering (does not apply to domestic fully insured Aetna plans).

Hub Pharmacies/Pharmacy Hub Service Providers

• Caremark is prohibited from interfering with “Hub Pharmacies’” ability to work with “Pharmacy Hub Service Providers. “Hub Pharmacies” are pharmacies that dispense prescription drug products as agents of “Pharmacy Hub Service Providers”, which are businesses that directly or through a vendor potentially streamline patient access to medication, improve affordability and support adherence through coordination and education usually through a digital platform;
• However, Caremark may enforce provisions, contractual terms, agreement or policies against a Hub Pharmacy service provider to control costs or maintain service or quality levels;

Transparency and Promotion

• Caremark will expand transparency efforts, including claim‑level reporting, data needed for Transparency in Coverage compliance, and broker payment information.
• Standard offerings will be promoted to plan sponsors in ways that support and retain community pharmacies (must spend a minimum of $10 million to advertise and market).

Organizational & Structural Changes

• All activities, employees, functions and assets used by Caremark for the purpose of rebate negotiation and contracting will remain based in the United States.

1. Certain provisions have later effective dates as noted. ↩︎

The information provided is a summary of laws and regulations relating to employee benefit plan compliance. This information should not be construed as legal advice. In all cases, employers should consult with their own legal counsel.