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Healthcare

CVS vs. Cigna: Which PBM Survives When Rebates Get Delinked

A 2026 appropriations-act mandate and an FTC consent order are forcing PBMs off rebate-driven pricing — and CVS Caremark's retail pharmacy arm has far more riding on the old model than Cigna's stand-alone Express Scripts.

Image: Money Racket

By Evan at Money Racket · Apr 7, 2026

The mechanism: Washington just did something PBMs spent two decades avoiding. The Consolidated Appropriations Act of 2026 delinks pharmacy-benefit-manager compensation from list prices in Medicare Part D, mandates flat-dollar "bona fide service fees" instead of rebate-percentage deals, and forces 100% rebate pass-through to employer plans (phasing in through 2029). Layered on top: the FTC's February 2026 consent order against Cigna's Express Scripts — and CVS Caremark's own March 2026 settlement-in-principle — both require a standard benefit design that lets plan sponsors exit spread pricing entirely and bars formularies from favoring high-list-price drugs to harvest bigger rebates. The rebate, the industry's core profit lever for thirty years, is being legislated and litigated out of existence. That reshuffles which PBM parent absorbs the hit.

Who cashes in:

Discussion

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