Cara Brown McCormick
WASHINGTON, D.C. — In less than a month, President Donald Trump has signed two major executive orders to overhaul the nation’s prescription drug pricing system. These orders have placed Pharmacy Benefit Managers (PBMs) at the center of the president’s ire and revived a controversial “Most Favored Nation” pricing policy that ties US drug prices to those abroad.
The first order, signed April 15, targets PBMs' opaque business practices. The second, signed on Monday morning, seeks to align US drug costs with the lowest prices paid by other developed nations. Together, the orders mark an aggressive reentry into drug pricing reform and spotlight the increasingly public and political battle over who’s responsible for America’s sky-high medication costs.
Of the two executive actions, the April 15 order may have broader and more immediate consequences by zeroing in on PBMs -- dominant, little-known intermediaries between drugmakers, insurers, and pharmacies. It instructs the Department of Labor to require employer-sponsored health plans to disclose all PBM compensation. It also calls on HHS, the FTC, the DOJ, and Commerce to investigate anti-competitive behavior in the pharmaceutical supply chain.
The new policy contained in the Executive Order includes a section dedicated to “Reevaluating the Role of Middlemen.” It states: “Within 90 days of the date of this order, the Assistant to the President for Domestic Policy, in coordination with the Secretary, the [Office of Management and Budget] Director, and the Assistant to the President for Economic Policy, shall provide recommendations to the President on how best to promote a more competitive, efficient, transparent, and resilient pharmaceutical value chain that delivers lower drug prices for Americans.”
Another section titled “Improving Transparency into Pharmacy Benefit Manager Fee Disclosure” states: “Within 180 days of the date of this order, the Secretary of Labor shall propose regulations pursuant to section 408(b)(2)(B) of the Employee Retirement Income Security Act of 1974 to improve employer health plan fiduciary transparency into the direct and indirect compensation received by pharmacy benefit managers.”
As IVN has reported for nearly a decade, including in its January 2025 report, “The Hidden Power of PBMs: A System Under Scrutiny,” PBMs are among the most powerful and least transparent actors in the US healthcare system. The top three: OptumRx, CVS Caremark, and Express Scripts control nearly 80% of all US prescription claims and have been accused of inflating costs, exploiting rebates, and undercutting independent pharmacies.
In a Truth Social post previewing the second order, Trump declared that the United States would no longer pay “five to ten times more” than other countries for the same drugs. He claimed the new pricing model would cut costs “by 30% to 80%” and save “trillions of dollars” by implementing a Most Favored Nation (MFN) rule across federal programs like Medicare. The MFN model, introduced initially during Trump’s first term, was blocked in court and later rescinded by the Biden administration.
Public, Legal, and Political Pressure Mounts
On May 11, The New York Times reported that CVS Caremark, one of the “big three” PBMs, decided to drop coverage of Zepbound, a newly approved obesity medication, in favor of the older drug Wegovy. The decision, which applies across its insurance clients, has forced patients already stabilized on Zepbound to switch medications, highlighting the power PBMs have to override clinical care decisions and upend treatment for cost or rebate-related reasons. Critics say this is a prime example of how PBMs’ formularies are driven less by medical need and more by undisclosed rebate deals and profit motives.
Mark Cuban: “It’s the PBMs That Have Screwed Things Up”
Amid the rising furor, entrepreneur Mark Cuban engaged in a high-profile social media clash on May 12 with conservative activist Charlie Kirk, who blames “Big Pharma” for high drug prices.
“Big Pharma’s lobbying of Washington DC has long allowed them to price gouge Americans. No more,” Kirk posted on X.
Cuban shot back that PBMs, not drugmakers, are the bigger problem:
“Drug prices are too damn high. But the big culprit isn't the brand manufacturers, it's the big middlemen. Namely PBMs. They work so hard to distort pricing the first lines in their contracts with everyone is ‘you can't disclose any of this.’ How bad are they? Have you ever seen them disclose a net price list? For your company Charlie, ask your PBM for a list of claims and the price paid for each med. Let us know if you can get them. This EO has a real shot. And Big Pharma isn't innocent. But it's the PBMs that have screwed things up. Separate formularies from PBMs and make them disclose all claims to employers and manufacturers and we may be able to get brand meds cheaper than many countries.”
Cuban’s remarks align with growing bipartisan frustration in Congress and among state attorneys general about the role of PBMs.
Sens. Maria Cantwell (D-WA) and Chuck Grassley (R-IA) re-introduced the Pharmacy Benefit Manager Transparency Act this year. The bill seeks to ban spread pricing, mandate rebate disclosures, and pass savings directly to consumers. It has broad support from AARP and over 200 advocacy organizations.
Cantwell has accused PBMs of creating “pharmacy deserts” and profiting at the expense of patients. “We should all be very concerned about the activities of PBM middlemen,” Cantwell said on the Senate Floor. “These are the people who are supposedly getting discounts for us on drug prices but then actually pocket those discounts.”
Grassley has said the bipartisan bill would save taxpayers $740 million.
Robert F. Kennedy Jr. also voiced support for PBM accountability following questioning by Senator Grassley during a January Senate hearing. “Trump is absolutely committed to fixing the PBMs,” Kennedy said at his confirmation hearing. “Trump wants to get the excess profits away from the PBMs and send it back to primary care, to patients in this country.”
What Happens Next
Whether Trump’s executive orders will survive legal scrutiny or succeed where earlier efforts failed remains uncertain. However, with lawsuits, legislation, public figures like Cuban, US senators, and major media outlets all sounding the alarm, PBMs, once the silent middlemen, are now facing intense pressure from all sides.
As Trump seeks to make lower drug prices a centerpiece of his presidency, these twin executive orders may be a turning point in the long-simmering debate and a new era of accountability for the PBM industry.