This has been a big month for drug pricing news.

Three separate stories. One common thread: drug pricing in America keeps shape-shifting, but the underlying economics rarely change as much as the headlines suggest.

I've covered these dynamics extensively over the past year, and this month’s news fits squarely into patterns we've already dissected together. So rather than start from scratch, I want to walk through what happened this month so far and connect it back to the bigger picture we've been building.

The FTC filed lawsuits against all three major PBMs—CVS Caremark, Express Scripts, and Optum Rx—back in 2024, alleging they inflated insulin prices through opaque rebate arrangements with drug manufacturers. Cigna's Express Scripts is the first to settle.

The core requirement: Express Scripts must now offer patients the lower-cost version of a drug rather than the version that maximizes PBM profit. On paper, that sounds like a win for patients, as they should see cheaper insulin (theoretically). But we need to look at this through the lens of how PBMs actually operate.

I covered the PBM business model in detail in my Middlemen Series.

The FTC settlement targets this exact behavior. However, Express Scripts settling doesn't mean CVS Caremark or Optum Rx will follow on the same terms, and it doesn't mean the underlying rebate model is going anywhere. Note, there’s no monetary penalty for Express Scripts.

We saw this play out in real time with Humira biosimilars. When biosimilars entered the market with prices up to 85% lower than brand-name Humira, PBMs were slow to adopt the cheapest options. Instead, the largest PBMs—including Express Scripts—launched their own private-label biosimilars through subsidiaries like Quallent Pharmaceuticals, effectively replacing one revenue stream with another they controlled directly. The biosimilar market is making progress, but PBM-driven rebate economics continue to slow adoption of the lowest-cost alternatives.

New CMS data on 2026 Medicare Part D enrollment shows that supermarket pharmacies—Albertsons, Publix—are now preferred in every major Part D plan. Walgreens is holding steady. But independent pharmacies are increasingly walking away from Part D networks entirely.

This matters for our patients, since many of the communities that depend most on independent pharmacies—rural areas, pharmacy deserts, underserved neighborhoods—are the same ones where medication access is already fragile. When independents exit Part D networks because reimbursement rates don't cover their costs, patients lose their most accessible pharmacy option.

I explored this dynamic in my piece on Amazon's Prescription Kiosks, where I broke down how retail pharmacy is consolidating. Walmart's pharmacy clinics are gone. Walgreens is going private after its healthcare bet failed. Dollar General pulled out. The survivors—Amazon and CVS—are building new distribution models (kiosks, delivery, subscription services) that work for urban and suburban patients but don't solve the access gap for everyone.

The Part D network data is another signal that the pharmacy landscape is being reshaped by economics, not patient need. Supermarkets are winning because they can absorb thin pharmacy margins as a loss leader for grocery traffic. Independents can't. Welp.

Axios reported that the Trump administration's drug pricing deals—the "most-favored-nation" arrangements powering TrumpRx (I wrote about it here)—barely registered as a concern for major drug companies. Wall Street analysts didn't even press on them. That tells you everything about how much the industry believes these deals will actually cost them.

I covered the TrumpRx model and pharma's broader direct-to-consumer strategy in my piece on Pharma's New DTC Playbook. The pattern is consistent: pharma agrees to "lower" prices through government-negotiated channels like TrumpRx, while underlying list prices and channel economics stay largely intact. Patients may pay less at the point of sale, and the administration gets a political win, but the fundamental power dynamic between manufacturers, PBMs, and payers doesn't shift.

Pfizer, Lilly, Novo, AstraZeneca, and others have all signed on to TrumpRx. They're offering discounts on specific drugs—sometimes steep ones. But these are strategic concessions, not structural reform. The companies are moving together, so the competitive landscape doesn't change. And as I wrote in November: the channel is changing more than the underlying incentives.

These three stories reveal the same pattern: drug pricing reforms are happening at the edges while core economics stay intact.

The players are adapting to pressure, but in ways that protect their core business. PBMs settle on insulin but keep rebates. Pharma cuts deal prices but keeps list prices. Supermarkets gain market share while pharmacy deserts grow.

The system keeps shifting and the question I have is whether it's moving toward patients or just rearranging around the same incentives.

In January 2026, nearly 15,000 NYC nurses struck for safe staffing, violence protections, and pay—plus a new demand: job security against AI.

Dr. Alyssa Chen argues AI threatens nursing differently than expected. It's targeting administrative roles that pulled experienced nurses away from bedside care.

AI now automates medication refills, pre-op calls, billing codes, and quality reviews—the desk work that became a burnout escape. Tools like Doctronic, for example, can replace hundreds of nursing hours.

When these administrative paths disappear, Dr. Chen suggests we might finally solve the nursing shortage.

👉 Read Dr. Chen’s full argument here.