The launch of the Trump administration’s TrumpRx drug platform in February 2026 is renewing scrutiny of prescription drug costs. Beyond sticker shock, the mechanisms behind drug pricing and access come down to the complexity of pharmacy benefit manager (PBM) systems that control coverage, rules, and distribution.
The TrumpRx prescription drug initiative aims to tackle one of the most visible problems in American healthcare: the high cost of medicines by offering patients manufacturer coupons and cash-pay options. However, some industry experts say real change won’t happen until policymakers look beyond pricing and examine the complex system determining how drugs reach patients.
Lower drug list prices can generate headlines. But many of the decisions that shape what patients pay and whether they receive treatment occur inside the network of pharmacy benefit managers (PBMs) that sit between drug manufacturers, insurers, pharmacies, and patients.
“Lowering some drug pricing doesn’t mean the patient will see a big difference,” said Paul Pruitt, Chief Growth Officer of SHARx, a champion for affordable access to medications he created with Corey Durbin.[1]
“The real power sits in the system that decides whether the drug is approved by your insurer, which pharmacy you must use to get it, and how industry rebates are structured,” Pruitt added.
The TrumpRx platform seeks to reduce prescription drug costs by expanding direct purchasing options and increasing pricing transparency. But most Americans still obtain medications through employer-sponsored insurance plans where PBMs determine coverage and reimbursement rules, according to reporting in The Hill.[2]
The PBM problem raises a growing question among policymakers and employers: Can drug price reform work if gatekeeping is embedded in the system and remains unchanged?
Hidden Gatekeepers and Drug Access
PBMs manage prescription drug benefits for hundreds of millions of Americans. In theory, they negotiate discounts with pharmacies to reduce costs. In practice, they also control many of the system’s most consequential decisions, including:
- Which drugs are covered;
- Which medications require prior authorization?
- What price is paid at the pharmacy,
- Which pharmacies patients are allowed to use; and
- How rebates and fees flow through the supply chain.
A 2024 Federal Trade Commission (FTC) report found that the largest PBMs now control most U.S. prescription drug claims, giving them significant influence over drug pricing and access. For patients, PBM authority often appears as an administrative hurdle. Prior authorization rules, step therapy requirements, and restricted pharmacy networks can delay treatment even when insurance technically covers the medication.
“Coverage doesn’t always mean access,” Pruitt noted.
“You can have insurance; you can have a prescription, and you can still spend weeks fighting through approvals just to start therapy,” he added.
Specialty Drugs Are Where the System Collides
The tension between pricing and access becomes especially clear in the specialty drug market, where the medications to treat some of healthcare’s most serious conditions, including cancer, autoimmune diseases, genetic disorders, and transplant complications, are accessed. Specialty Pharmacy Continuum recently reported that specialty drugs also represent the fastest-growing segment of prescription drug spending. At the same time, insurers and PBMs often apply the strictest utilization controls to these therapies.
Reporting in Drug Store News suggests PBMs may expand prior authorization requirements for certain high-cost specialty therapies. In some cases, patients must obtain these medications exclusively through specialty pharmacies owned by the same companies that manage their drug benefits.
“Specialty drugs are where the financial incentives really collide and compound,” Pruitt explained.
“Pricing, distribution, and approvals all run through the same system.”
Vertical Integration Raises Policy Questions
Regulators have also increased scrutiny of the growing vertical integration among PBMs, insurers, and pharmacies. Many of the nation’s largest PBMs now operate within large healthcare conglomerates that also own insurance companies and pharmacy networks.
According to the Federal Trade Commission (FTC), PBMs sit “at the center of the complex pharmaceutical distribution chain,” which gives them visibility and influence across multiple layers of the drug market. Critics say this structure can create overlapping financial incentives that employers and patients struggle to understand.
“When the insurer, PBM, and pharmacy are owned by the same organization, it’s like refereeing your own game,” Pruitt said. “The same company can influence pricing, approvals, and where the drug is filled.”
The Employer Push Back Era
Employers, who sponsor health coverage for more than half of Americans, are increasingly scrutinizing the pharmacy benefit system as prescription drug costs continue to rise. Many plan sponsors say their biggest challenge is understanding where their healthcare dollars go.
Several media investigations into employer health plans have highlighted growing frustration among companies as they try to untangle rebate structures and hidden fees embedded in the drug supply chain. Without transparency into contracting terms and rebate flows, employers often struggle to determine the true cost of medications.
“You cannot meaningfully lower drug prices without addressing rebates, a significant portion of the list price is tied to the contracting system that sits between the manufacturer and the patient,” Pruitt explained.
Bigger Policy Questions
The renewed focus on drug prices reflects decades of political pressure to hold pharmaceutical manufacturers accountable for the rising costs that many healthcare economists say are driven by the convoluted pharmaceutical supply chain.
“In most industries, you can see the price of what you’re buying. With prescription drugs, the price is hidden in a maze of contracts that most employers can’t even audit. If policymakers want real reform, they must find a way to break down this maze and address the incentives built into the middle of the system,” Pruitt said.
“Otherwise, price cuts risk disappearing before they ever reach the patient. For patients with serious illnesses, the consequences are immediate. When someone with cancer or a rare disease needs medication, they are thrust into a system that feels like a multi-layered obstacle course of roadblocks, gatekeepers, and red tape. But for many families, that’s exactly what happens. For many patients and their doctors, the challenge is not about finding the right medicine. It’s about surviving the levels of bureaucracy to get and afford their medicine,” he concluded.
References
[1] Goldman, M. (2026, Feb. 25). Trump touts drug price reductions most Americans may not feel. Axios. (Article)
[2] Choi, J. (2026, Feb. 25). Trump lauds his online drug platform as prescription drug win. The Hill (Article).
[3] Federal Trade Commission. (2024, July 9). FTC interim staff report on pharmacy benefit managers. [Article]
[4] Shaw, G. (2026, Feb. 24). Higher-cost specialty therapies moving up. Specialty Pharmacy Continuum. [Article]
[5] Levy, S. (2026, Feb. 26). CVS Caremark advances prior authorization for specialty medications. Drug Store News.[Article]
Featured image: © 2019 – 2026 Fotolia/Adobe. Used with permission.
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