FTC’s PBM insulin price case stalled after Trump firings

FTC’s administrative complaint

On Sept. 20, 2024, the Federal Trade Commission (FTC) voted to file an administrative complaint against the nation’s three largest pharmacy benefit managers (PBMs) -- CVS Caremark, Cigna's Express Scripts and UnitedHealth’s OptumRx. The case also involves the PBMs’ respective group purchasing organizations (GPOs), Zinc, Ascent and Emisar.

The complaint alleges the PBMs ''rigg[ed] pharmaceutical supply chain competition in their favor'' by exploiting a ''perverse drug rebate system that prioritizes high rebates from drug manufacturers.''

Filed in a 3-0-2 party-line vote, the administrative complaint accuses the firms of colluding to inflate insulin prices for patients by up to 1,200% over the past two decades. The vote was carried out by then-Chair Lina Khan (D), Rebecca Slaughter (D) and Alvaro Bedoya (D) after Melissa Holyoak (R) and Andrew Ferguson (R) recused themselves without a public explanation.

Administrative adjudication process

Unlike typical federal court litigation, this case is being handled through the FTC's administrative adjudication process. Under this system, the agency addresses disputes and enforces consumer protection and competition laws internally.

The process begins with a formal complaint and investigation, followed by a hearing before an Administrative Law Judge -- an independent adjudicator operating within the executive branch. The FTC's commissioners then issue the final decision.

However, Holyoak and Ferguson's recusal and Trump's decision to fire the two remaining Democratic commissioners have left no one to continue the process on the FTC's behalf.

FTC paralysis

Despite her term as Chair officially ending under the Biden–Harris administration on Sept. 26, 2024, Khan resigned from the FTC on Jan. 31, 2025, after Trump appointed Ferguson as the new Chair 11 days prior.

Then, on March 18, 2025, Trump abruptly terminated the agency's only two remaining Democratic commissioners -- Slaughter and Bedoya -- without cause. Their dismissals directly challenge a longstanding legal precedent established in Humphrey’s Executor v. United States, a 90-year-old ruling that limits the presidential power to remove FTC commissioners without cause.

In a lawsuit filed on March 27, 2025, the commissioners described the firings as a ''direct violation of a century of federal law and Supreme Court precedent,'' calling Trump’s actions legally ''indefensible.''

With no new commissioners confirmed, the FTC now lacks a quorum to proceed with the case.

Official stay order

On March 31, 2025, the FTC's Complaint Counsel and the BPM and GPO respondents jointly moved for an expedited stay of the administrative proceeding. Under FTC Rule 0.7(b), which permits the General Counsel to act in the absence of a quorum when all parties waive the right to a Commission review, the stay was granted.

Key elements of the order include the following:

• A minimum stay period of 105 days.
• An evidentiary hearing is scheduled 225 days after the stay is lifted.
• A requirement that the parties engage in good-faith discussions regarding future scheduling and the lifting of the stay.

In a post on the social media platform X, former FTC Chair Khan criticized the stay, calling it ''a gift to the PBMs.''

Industry and regulatory implications

The pause in the FTC’s case has immediate and significant implications:

• Continued high insulin prices. With the case on hold, any potential remedies to lower insulin costs remain deferred, affecting millions of patients with diabetes who already face exorbitant out-of-pocket expenses.
• Regulatory uncertainty. The inability to move forward with the case raises broader questions about the independence of regulatory agencies. The firings of Slaughter and Bedoya have ignited debates over executive overreach and the future role of independent regulatory bodies in enforcing antitrust laws.
• Bipartisan policy debate. Despite the leadership impasse, PBM reform retains bipartisan support. Both previous administrations have signaled interest in addressing drug pricing, though the current political standoff may delay meaningful action until at least 2026.

Looking ahead

As the FTC remains in a procedural deadlock, stakeholders across the industry will be closely watching. The outcome of the legal challenge to the commissioners' firings and the eventual reconstitution of the FTC's quorum will be fundamental in determining when or if the agency can resume its review of PBM practices and work toward lowering patients' insulin costs.

Alivia Kaylor is a scientist and the senior site editor of Pharma Life Sciences.