If Someone in Your House Is on Insulin, the FTC Just Capped What CVS Can Charge You

If your household fills an insulin prescription, the price you pay at the pharmacy counter is about to change.

The Federal Trade Commission and CVS Caremark, the country’s biggest pharmacy benefit manager, cut a deal on July 14. CVS agreed to cap what plan members pay for insulin at $25 a month, delink the fees it earns from drug list prices, and pass rebates through to members at the register. The FTC’s estimate on what this saves consumers: up to $8.5 billion over the next decade, plus another $4.5 billion from point-of-sale rebates.

Not free. Twenty-five dollars a month. But that is the number to walk into the next open enrollment with in your head.

What was going on

Pharmacy benefit managers are the middlemen who decide which drugs your plan covers and what they cost you at the counter. Three of them, Caremark, Express Scripts, and Optum Rx, run about 80% of all US prescriptions. The FTC sued all three in 2024, alleging they built a rebate system that preferred more expensive versions of insulin because bigger list prices meant bigger rebates flowing back to the middleman. Patients whose copays are set from the list price paid more so the rebate could be fatter.

FTC Chair Andrew Ferguson’s own words: the deal “brings billions in real savings to consumers feeling the pinch from excessive prescription drug prices.”

Caremark’s response, from the CVS press release, is that it has “led the industry” and the agreement “advances and reinforces the changes we have already put in place.” Read that with a straight face. A company saying it is happy to be forced into best practices it was leading on.

Express Scripts settled in February. Optum Rx is still negotiating. Two of the big three are done.

What this means for your bill

If you or someone in your house is on insulin under a Caremark-managed plan, the max out-of-pocket for that prescription is now $25 a month. At today’s list prices, that is real money. A monthly insulin fill under commercial insurance without a cap can hit $80 to $150 or more depending on the drug, the plan, and the deductible. Cut that to $25 and a full year of insulin drops from roughly $1,000 to $1,800 down to $300. Over the ten years the FTC is projecting, the aggregate is $8.5 billion.

The point-of-sale rebate change is quieter but touches everyone with a Caremark prescription, not just diabetics. Right now the manufacturer rebate goes back to the plan, not you. Under the settlement, standard Caremark plans will pass through rebates at the register on a broader set of drugs. That means the coinsurance you pay on a covered drug gets calculated after the rebate, not before. The FTC put the size of that transfer at up to $4.5 billion.

For anyone whose plan sponsor buys the standard offering, that shows up as a smaller number on the receipt.

Do this at open enrollment

Check the back of your insurance card. If the pharmacy benefit manager is CVS Caremark, you are inside the ring the settlement covers. Ask HR two questions this fall. Is our plan sponsor opting out of the $25 insulin cap in writing? Is our plan on Caremark’s standard commercial offering with point-of-sale rebate pass-through? If the answer to the second one is no, ask why not, because that is where the second pool of savings lives.

If your card says Express Scripts, you already sit under a similar settlement from February. Same questions apply. If it says Optum Rx, file this away and ask again next year.

Do it before you pick next year’s plan, not after. The pharmacy counter is where these terms show up first, and by then the enrollment window is closed.

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