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Twice-Weekly Briefing
Friday, August 28, 2026
Issue 260828-58
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The MOC Brief
Health policy, priced and translated for self-funded plan sponsors
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In This Edition
Five developments from the past week, and what each one costs you.
| 1. | What large employers are budgeting for 2027, and what plan design takes back | | 2. | Florida sues Prime Therapeutics and Express Scripts over pharmacy reimbursement | | 3. | A first-in-class pancreatic cancer drug lengthens the most expensive claims you pay | | 4. | The DEA's telehealth special registration rule reaches OMB for final review | | 5. | The FTC finalizes seven surgery center divestitures in a $3.9 billion deal |
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| 1 · Cost Trend · August 25, 2026 |
| Large Employers Put Their 2027 Cost Increase at 9.2 Percent Before Plan Changes and 8 Percent After |
| Business Group on Health published its 2027 Employer Healthcare Strategy Survey on August 25. The 127 employers who completed it in June 2026 put their median 2027 trend at 9.2 percent before plan design changes and 8 percent after, against 8.5 percent and 7 percent for 2026. Those employers cover 8.7 million people in the United States. Pharmacy now accounts for 25 percent of their total health spend, and employer drug costs are estimated to rise 12 percent in 2026, faster than overall trend. Cancer was named the top cost driver by 70 percent of respondents, up from 58 percent a year earlier, with 92 percent placing it in their top three. |
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MOC Perspective
The number to work with is not the trend, it is the 1.2 point gap between the two figures. That gap is everything plan design changes are expected to buy for 2027. Deductibles, copays, and contribution strategy get you just over a point. Everything past that comes from network, site of care, and pharmacy contracting, and none of those moves a full point alone. These 127 employers cover 8.7 million U.S. lives, so read 8 percent as what that scale of purchasing buys, not as your floor.
What to do now
| ▪ | Model your 2027 renewal at both figures and put a dollar value on what plan design is actually expected to buy. | | ▪ | Pull your last 24 months of oncology claims before renewal, since 70 percent of survey respondents now call cancer their top cost driver. | | ▪ | Confirm what share of your total spend runs through the pharmacy benefit, against the 25 percent these employers report. |
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| Source: Business Group on Health |
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| 2 · PBM Antitrust · August 27, 2026 |
| Florida Sues Prime Therapeutics and Express Scripts Over an Agreement It Calls Illegal Per Se |
| Florida Attorney General James Uthmeier filed suit on August 27 in the Circuit Court of the Tenth Judicial Circuit in Polk County against Prime Therapeutics, which the complaint calls the sixth largest pharmacy benefit manager in the country, and Express Scripts, which it calls the second largest. The complaint pleads three counts: conspiracy in restraint of trade under Florida Antitrust Act section 542.18, a Florida Deceptive and Unfair Trade Practices Act claim for conduct before January 1, 2024, and unjust enrichment. It describes an arrangement the two companies announced on December 19, 2019 and put into effect on April 1, 2020, which the state says Prime itself valued at $2.5 billion over its first three years. Florida alleges pharmacy reimbursement from Prime then fell for around 80 percent of branded drugs and 70 percent of generics, with one pharmacy outside Orlando seeing a single drug drop 45 percent to $34.16, a loss of $15.45 per prescription. The complaint pleads the agreement as illegal per se and asks for treble damages, civil penalties, disgorgement, and a jury trial. |
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MOC Perspective
Read this as a discovery event, not a verdict. Florida's theory is about what pharmacies get paid, and the complaint does not allege that employers were overcharged, so do not expect a refund. What it does produce is a public record of how two very large PBMs set network reimbursement, and the complaint itself describes PBMs as acting on behalf of plan sponsors, typically employers. If either company touches your self-funded pharmacy benefit, your audit rights are the only way you will see whether the same rate methodology sits under your plan.
What to do now
| ▪ | Check whether Prime Therapeutics or Express Scripts administers any part of your pharmacy benefit, including through a Blue plan arrangement. | | ▪ | Read your PBM contract's audit clause this quarter and confirm you can inspect what network pharmacies are paid, not only what you were billed. | | ▪ | Ask your PBM in writing whether any reimbursement agreement with another PBM applies to your contract, and get the answer before your next renewal. |
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| Source: Office of the Attorney General, State of Florida |
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| 3 · Cancer Spend · August 26, 2026 |
| The FDA Approves a First-in-Class Pancreatic Cancer Drug That Roughly Doubles Median Survival |
| The FDA approved Rasonque, daraxonrasib, from Revolution Medicines on August 26 for adults with metastatic pancreatic adenocarcinoma who have had at least one prior systemic therapy or cannot take multiagent therapy. The FDA calls it first in class, and Revolution Medicines describes it as the first broad RAS targeted medicine in metastatic pancreatic cancer. In a randomized, open label trial of 500 previously treated adults, median overall survival was 13.2 months against 6.7 months on chemotherapy. Revolution Medicines identifies that trial as RASolute 302 and reports median progression free survival of 7.2 months against 3.6 months. The application carried Breakthrough Therapy and Orphan Drug designations, ran under Priority Review, and used the Commissioner's National Priority Voucher pilot. The company says it is available to prescribe now, and neither release states a price. |
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MOC Perspective
A pancreatic cancer case that used to close out around six months now runs past a year, and every extra month is more drug fills, imaging, and supportive care you pay for. It lengthens the tail on some of the most expensive claims your plan will see. With no published price, your stop-loss carrier will price that uncertainty into your renewal before you see a single claim. Ask now rather than at renewal.
What to do now
| ▪ | Ask your stop-loss carrier how it is pricing 2027 oncology approvals, and get the answer in writing. | | ▪ | Confirm whether this drug adjudicates under your pharmacy benefit or your medical benefit, because utilization management sits in different places. | | ▪ | Add oral oncolytics to the specialty drug list your PBM reports on monthly, so a six figure case does not reach you first through stop-loss. |
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| Source: U.S. Food and Drug Administration |
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| 4 · Telehealth Access · August 25, 2026 |
| The DEA Sends Its Telehealth Special Registration Rule to OMB for Final Review |
| The Drug Enforcement Administration sent its final rule on Special Registrations for Telemedicine and Limited State Telemedicine Registrations, RIN 1117-AB40, to the Office of Information and Regulatory Affairs on August 25. The OIRA record lists it at the final rule stage, marks it economically significant, and records a statutory deadline. Review at OIRA is the last step before a rule publishes, and the text stays confidential until then. This framework decides how clinicians prescribe controlled substances to patients they have not examined in person. That is the mechanism behind virtual behavioral health and ADHD care. Nothing in the record says when review will finish or what the rule contains. |
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MOC Perspective
Your telehealth vendors have been prescribing under temporary flexibilities extended again and again, and this is the standing framework meant to succeed them. If the special registration comes out narrow, the vendor you use for behavioral health, ADHD, or medication assisted treatment may lose the ability to serve part of your population, and members already on a controlled substance feel it first. You cannot plan against text nobody has seen, but you can find out this week whether your vendor has a contingency and who tells your members.
What to do now
| ▪ | Ask your telehealth and behavioral health vendors in writing what they will do if the DEA special registration narrows remote prescribing. | | ▪ | Count how many members currently receive a controlled substance through a virtual visit, using your pharmacy claims. | | ▪ | Name now the person who drafts member communication if prescribing rules change mid plan year, before the rule publishes. |
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| Source: Office of Information and Regulatory Affairs |
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| 5 · Provider Consolidation · August 25, 2026 |
| The FTC Finalizes Seven Surgery Center Divestitures in Ascension's $3.9 Billion AmSurg Deal |
| The Federal Trade Commission approved a final consent order in the Ascension Health and AmSurg transaction on August 25, File No. 251-0093, voting 2 to 0 after a public comment period. Ascension must divest seven AmSurg ambulatory surgery centers across five metro areas: Nashville, Panama City, Tulsa, Waco, and Wichita. Six go to SC Affiliates and the Panama City center goes to Florida Gastroenterology Center. The Commission alleged the deal would limit competition for outpatient surgical services performed by gastroenterologists, ophthalmologists, and orthopedists, and said that limited competition would likely lead to higher surgery prices for patients while threatening to lower quality of care and limit innovation in surgical services. The order also requires Ascension to give the Commission prior notice of any future surgery center acquisition in the metro areas around the divested sites. The underlying transaction is valued at $3.9 billion. |
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MOC Perspective
This is the FTC alleging, and then settling on an enforceable remedy, that surgery center concentration in these five markets would likely have raised the price of outpatient surgery. Your steerage program pushes members to surgery centers because they cost less than a hospital outpatient department, and that saving depends on there being more than one center in the market to price against. Five metro areas just got a remedy. Nothing in this order reaches the markets your own members actually use, and that is where your unit cost moves without anyone telling you.
What to do now
| ▪ | List your top five metro areas by outpatient surgical spend and count the independent surgery centers in each one. | | ▪ | Ask your network vendor whether any site in your steerage program changed ownership in the last 24 months. | | ▪ | Compare your allowed amount per case at surgery centers against hospital outpatient departments in the same market, using 12 months of claims. |
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| Source: Federal Trade Commission |
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The Bottom Line
Four of these five stories land on the same line of your plan: what one unit of care costs, and who sets that price when you are not in the room. Plan design gets you 1.2 points of the 9.2 percent these employers are budgeting for 2027. The rest has to come out of the pharmacy contracting Florida's case is about to put on the public record, the surgery center market the FTC just had to referee, and the specialty drugs whose price nobody has published yet. Each of those is decided in a contract you can open this quarter and cannot reopen once your plan year starts.
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Jude Odu
Founder and Principal, Model Optimal Care
Author of Model Optimal Care: End U.S. Healthcare Waste, One Health Plan at a Time
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