| 1 · PBM Enforcement · July 14, 2026 |
| FTC Locks In $8.5 Billion in the Caremark Settlement |
| The Federal Trade Commission announced a consent settlement on July 14 with Caremark Rx and Zinc Health Services. It requires the CVS-owned PBM to delink its fees from drug list prices, offer retail community pharmacies a cost-plus reimbursement model, and stop interfering with pharmacies that work with hub service providers. The FTC estimates the terms lock in up to $8.5 billion in consumer savings over 10 years and unlock another $4.5 billion in point-of-sale rebate value. The deal follows the February 4 Express Scripts settlement and now covers two of the three PBMs that control roughly 80 percent of U.S. prescription volume. A 30-day public comment window runs before the order is final. |
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MOC Perspective
You now have a federal benchmark for what a defensible PBM contract looks like: fees delinked from list price, retail pharmacies offered cost-plus economics, and no unilateral steering to captive dispensing channels. Treat the two FTC settlements as the new floor for ERISA Section 408(b)(2) reasonableness. If your plan runs through CVS Caremark, Express Scripts, or OptumRx, the question is whether you are getting the terms the government just required.
What to do now
| ▪ | Request written confirmation that your plan receives the same delinked fee structure and cost-plus pharmacy option the FTC required. | | ▪ | Put a 30-day termination-for-convenience clause on your next PBM renewal. | | ▪ | Add a covered-service-provider disclosure test to your annual fiduciary calendar. |
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| Source: Federal Trade Commission |
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| 2 · Drug Pricing · July 16, 2026 |
| CMS Opens a Third Medicare Drug Price Negotiation Cycle With 15 Drugs in Play |
| CMS published final program guidance on July 16 for Initial Price Applicability Year 2028 of the Medicare Drug Price Negotiation Program. The third cycle covers up to 15 Part D and Part B drugs whose Maximum Fair Prices take effect January 1, 2028. The guidance codifies expanded orphan drug protections under Public Law 119-21, tightens manufacturer effectuation timelines, and formalizes transparency requirements around negotiation offer justifications. CMS also opened a 60-day comment window on a companion proposed rule that would make the program mechanics permanent under 42 CFR, with comments due August 17. |
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MOC Perspective
Medicare Maximum Fair Prices are on their way to becoming a reference point for commercial specialty and biologic contracting, not a Medicare-only artifact. Each new MFP list is an anchor benchmark you should flag in your PBM rebate reconciliations. The gap between your net commercial cost and the published federal price is the number your PBM will not volunteer.
What to do now
| ▪ | Require your PBM to produce a side-by-side of net commercial cost against the announced MFP for every Part B and Part D drug on the negotiation list. | | ▪ | Add a most-favored-nation clause tied to Medicare MFPs at your next renewal. | | ▪ | Log the August 17 comment deadline and file a written employer-perspective letter through your coalition. |
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| Source: CMS |
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| 3 · Legislation · July 16, 2026 |
| House Ways and Means Advances Seven Healthcare Bills in One Markup |
| The House Ways and Means Committee approved seven healthcare bills on July 16, moving legislation on Medicare Advantage prior authorization, price transparency, long-term acute care hospital payment, nursing home oversight, and rural access to the House floor. H.R. 3514, the Improving Seniors' Timely Access to Care Act of 2026, cleared unanimously. It would require Medicare Advantage plans to adopt electronic prior authorization, publish approval and denial data, and cut turnaround times for routine and expedited requests. The party-line H.R. 9645 would extend hospital and payer price transparency obligations to all commercial payer contracts and tie enforcement penalties to average daily patient revenue. |
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MOC Perspective
Prior authorization and price transparency just moved from advocacy talking points to committee-cleared bill numbers with a live path to floor votes before recess. That is advance notice to convert soft carrier promises into contract language now, while you still have room to bargain and before compliance becomes mandatory and free.
What to do now
| ▪ | Require your carrier and TPA to publish quarterly prior authorization approval, denial, and turnaround statistics at the plan level. | | ▪ | Add a service-level agreement for the gold-carding conditions listed in H.R. 3514. | | ▪ | Confirm your payer-side machine-readable file already covers 100 percent of your in-network hospital contracts. |
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| Source: House Ways and Means Committee |
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| 4 · 340B · July 2026 |
| Bipartisan SECURE 340B Act Reopens the Discount Statute After 15 Years |
| A bipartisan group of House Energy and Commerce members introduced the SECURE 340B Act this month, a 142-page bill that redefines patient eligibility, limits child site registration, protects contract pharmacy arrangements from manufacturer restriction, and installs an independent HRSA-managed clearinghouse to reconcile 340B claims. It follows a competing Senate framework unveiled June 25 by HELP Chair Bill Cassidy focused on rebate models and outpatient hospital carve-outs. Committee analysis projects the House bill would generate roughly $8 billion in 340B claim savings and reduce contested manufacturer restrictions across 42 state 340B laws. |
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MOC Perspective
A statutory rewrite of 340B resets commercial hospital pricing math, because covered entities cross-subsidize their negotiated commercial rates with 340B margin. Squeeze that margin and the hospital comes looking for it somewhere else, and your plan is the somewhere else. The SECURE 340B Act and the Cassidy draft are leading indicators of a commercial rate reset you can price now.
What to do now
| ▪ | Ask your consultant for a written exposure analysis of the top five in-network 340B covered entities your plan uses. | | ▪ | Request from those hospitals a copy of their 340B savings estimate for your plan population. | | ▪ | Add a rate escalator cap tied to CMS OPPS 340B payment rules at your next hospital contract renewal. |
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| Source: FDA Law Blog |
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| 5 · Medicare Advantage · July 2026 |
| Medicare Advantage Quality Bonuses Reach $13.4 Billion in 2026 |
| A KFF analysis released this week estimates federal spending on the Medicare Advantage quality bonus program will hit $13.4 billion in 2026, up from $12.7 billion in 2025 and more than quadruple the $3.0 billion spent in 2015. The share of Medicare Advantage enrollees in bonus-qualifying plans fell to 68 percent from 75 percent in 2025, the lowest since 2018. UnitedHealth Group takes the largest incremental payment at $3.9 billion, while Kaiser Foundation Health Plans receives the highest bonus per enrollee at $577. Total bonus payments now equal 2.3 percent of the projected $574 billion in Medicare Advantage plan payments for 2026. |
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MOC Perspective
A $13.4 billion federal payment tied to a rating system the same insurers are actively litigating is a governance signal for any employer offering a group retiree Medicare Advantage plan. Star ratings are an indirect but material term of the plan you are buying, and a mid-contract repricing is a real outcome, not a hypothetical one.
What to do now
| ▪ | Require your retiree Medicare Advantage carrier to disclose its plan-specific star rating trajectory over the past three cycles. | | ▪ | Ask for the share of quality bonus revenue attributable to your membership. | | ▪ | Get written disclosure of any pending or filed CMS star ratings litigation that could reprice your plan mid-contract. |
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| Source: KFF |
