Drug pricing in 2026 is being reshaped at the pharmacy counter, in federal agencies and in courtrooms — all at once.
Within a single month, CMS finalized another round of Medicare price cuts affecting $42.5 billion in annual Part D spending; the Federal Trade Commission required one of the nation’s largest PBMs to overhaul insulin pricing practices; CVS began accepting federally backed discount cards at 9,000 pharmacies; and Amazon expanded same-day prescription delivery to 4,500 cities. Meanwhile, manufacturers escalated pricing disputes through new federal challenges to emerging pricing models.
At the same time, the 340B landscape remains unsettled. HHS dropped its proposed rebate-based pilot program following court rulings but is seeking feedback on potential redesign options, leaving safety-net hospitals planning around continued policy uncertainty.
For hospital and health system leaders, the changes are no longer theoretical. Pharmacy economics are being recalibrated in real time — through statute, voluntary agreements and proposed federal payment models.
Here are the forces driving that shift:
1. Federal pricing authority is expanding through multiple channels.
The most durable shift underway is Medicare drug price negotiation under the Inflation Reduction Act.
The program’s first negotiated prices took effect Jan. 1 for 10 high-expenditure Part D drugs. CMS will implement lower maximum fair prices for 15 additional drugs in 2027, covering medications that accounted for $42.5 billion in Medicare Part D gross prescription costs in 2024. The agency projects $12 billion in savings from that cycle alone. In 2028, negotiations will expand to certain physician-administered Part B drugs, including Botox.
That authority was explicitly granted by Congress, and implementation is already operational.
Running parallel is the administration’s most-favored-nation pricing strategy.
Since September, 16 of the 17 largest drugmakers have signed voluntary agreements tying portions of their portfolios to international price benchmarks. Those agreements apply primarily to Medicaid and certain cash-paying consumers. They also underpin TrumpRx.gov, a federal direct-to-consumer platform listing more than 40 brand-name drugs — including GLP-1 therapies and insulin — at internationally benchmarked prices.
More consequential for Medicare are two proposed CMS demonstration models — GLOBE (Part B) and GUARD (Part D) — that would apply international reference pricing inside Medicare itself. Unlike IRA negotiation, these pilots rely on CMS demonstration authority rather than standalone congressional legislation and are expected to face legal challenges if finalized.
The result is a multi-track pricing environment: one program statutorily embedded and expanding, another voluntary and market-facing, and a third potentially transformative but legally unsettled.
2. Direct-to-consumer pricing is now a public benchmark.
TrumpRx is more than a website. Together with IRA negotiation and proposed MFN pilots, the platform shifts pricing authority from closed-door rebate negotiations into visible, consumer-facing benchmarks.
CVS pharmacies now accept TrumpRx discount cards nationwide, embedding federally negotiated prices into 9,000 retail locations, and GoodRx powers pricing for dozens of medications on the platform.
While TrumpRx prices are not always the lowest option for insured patients, the site establishes a visible cash benchmark. Drug pricing structures that once lived primarily inside rebate contracts and payer negotiations are now publicly searchable.
At the same time, federal transparency mandates continue to expand. In 2026, both hospitals and payers must update their machine-readable files, with hospitals adding executive attestation and new reporting requirements and payers transitioning to a more standardized data format.
Negotiated ceilings, voluntary international benchmarks and public pricing files are converging to make pricing more visible — and more comparable.
Hospital pharmacies are no longer operating solely within plan-negotiated copays. They are functioning in a market in which statutory ceilings and transparent cash prices increasingly intersect.
3. PBM reform has moved into enforcement mode.
After years of scrutiny, PBM oversight is showing up in formal enforcement actions across multiple agencies.
The FTC reached a settlement requiring Express Scripts to delink manufacturer compensation from list prices, expand insulin savings programs and increase transparency to plan sponsors. At the same time, the Labor Department proposed new disclosure requirements for PBM compensation arrangements with self-insured employers. Federal legislation also directs CMS to strengthen Medicare Part D contract oversight beginning in 2028, including audit and enforcement authority.
States are adding another layer of pressure. North Carolina’s SCRIPT Act requires PBMs to pass negotiated savings to patients, allow any willing pharmacy into networks and submit annual reports to regulators.
For health systems operating specialty pharmacies or partnering with PBMs, oversight is becoming multidimensional — spanning federal enforcement, employer disclosure demands and state regulatory expansion.
4. Retail competitors are accelerating consumer-facing models.
Retail pharmacy operators are responding to pricing pressure with scale and speed.
Amazon Pharmacy will expand same-day prescription delivery to 4,500 cities by the end of 2026 and continues to promote its $5-per-month RxPass subscription program. CVS has embedded federal discount programs into its nationwide footprint. Walgreens went private and split into five standalone companies following multibillion-dollar operating losses, positioning itself for long-term restructuring.
These moves reflect a shift toward convenience, subscription pricing and transparent cash benchmarks as competitive differentiators.
Hospital-based pharmacy, by contrast, remains largely integrated into care delivery and enterprise reimbursement systems. That alignment supports care coordination but does not inherently compete on speed or subscription economics.
5. 2027 is an operational inflection point.
For health system leaders, the shift heading into 2027 is about operating in a pricing environment with clearer boundaries — and less insulation.
IRA negotiation will expand. Transparency requirements will tighten. PBM compensation faces greater scrutiny. Voluntary MFN agreements may be codified through congressional action, depending on legislative outcomes.
At the same time, proposed international reference pricing pilots for Medicare introduce legal and timing uncertainty that could shape implementation timelines.
That combination is reshaping contracting dynamics and long-range planning. Specialty pharmacy margins, infusion services and outpatient growth strategies must now account for negotiated price ceilings, public benchmarks and evolving regulatory oversight.
The question for 2027 is not whether disruption continues. It is how well pharmacy operations are aligned for a market in which pricing authority is more visible and more tightly regulated than before.
