US makes drug middlemen show employers every payment they get, under a rule that starts in July 2027

The stories

10 stories on this beat today.

Every story told the same way: what happened, who is involved, why it matters, how it works, the truth and the good news.

1. 01

   US makes drug middlemen show employers every payment they get, under a rule that starts in July 2027

   $22bn

   cut in drug costs over ten years, the US Labor Department estimates

   STAT reports officials' figure as more than $800 million a year [1][2]

   130,000

   employers covered by the rule

   along with more than 70 PBMs, officials estimate [2]

   80%

   of US prescriptions handled by just three PBMs

   Express Scripts, Caremark and Optum Rx, each owned by a health giant [1]

   11.5%

   expected rise in drug costs in 2026

   after a 9% rise the year before, the advisory firm WTW says [1]

   What happened

   • The US Labor Department finalised a rule on Thursday aimed at drug middlemen called PBMs. [1]
   • PBMs, or pharmacy benefit managers, run the drug side of health plans for employers. [1]
   • The rule makes them show those employers every payment they get from drugmakers and others. [1]
   • It covers more than 70 PBMs and 130,000 employers, US officials estimate. [2]
   • One payment to be shown is the rebate a drugmaker pays the PBM on a medicine. [1]
   • Another is the spread, money the PBM keeps on each prescription. [1]
   • The spread is the gap when a plan pays the PBM more than the pharmacy gets. [1]
   • Fees from brokers and consultants must be shown too, since they can be conflicts of interest. [2]
   • Payments that might steer patients towards certain drugs must be shown, the Wall Street Journal reported. [3]
   • PBMs must share the figures at each new contract and every six months. [1]
   • Employers may audit those figures once a year. [1]
   • A PBM that does not comply faces fines and can lose its contract. [1]
   • The department says the rule will cut drug costs by $22 billion over ten years. [1]
   • STAT, a US health news site, reports officials' estimate as more than $800 million a year. [2]
   • Three PBMs handle about 80% of all US prescriptions. [1]
   • They are Cigna's Express Scripts, CVS's Caremark and UnitedHealth's Optum Rx, all owned by health giants. [1]
   • Their size has fuelled calls for the US Congress to break them up. [1]
   • WTW, an advisory firm, expects drug costs to rise 11.5% in 2026, after 9% in 2025. [1]
   • Just under half of large employers say they can see what drugmakers pay their PBM. [1]
   • US Labor Secretary Keith Sonderling said PBMs had been "pocketing hidden fees" for years. [1]
   • James Gelfand of the ERISA Industry Committee, a big employers' group, welcomed the rule. [1]
   • PBM groups argued the department has no legal power to force these disclosures. [1]
   • They also said the reporting would be hardest on mid-sized PBMs. [1]

   Who is involved

   • US Labor Department the US government department for workers' pay and benefits; it wrote and finalised the rule
   • PBMs run drug benefits for employers
   • Brokers
   • Consultants
   • Express Scripts owned by Cigna
   • Caremark owned by CVS
   • Optum Rx owned by UnitedHealth
   • James Gelfand head of the ERISA Industry Committee
   • Employers
   • Their workers
   • Express Scripts, Caremark and Optum Rx the three biggest PBMs, owned by Cigna, CVS and UnitedHealth; they handle about 80% of US prescriptions
   • ERISA Industry Committee a group for large US employers that pay their workers' health bills; it welcomed the rule

   How it unfolded

   The department proposed the rule in January and finalised it on 29 October, over PBMs' objections. [1]

   1. January rule proposed
   2. 29 October rule finalised
   3. 1 July 2027 disclosures begin
   4. January 2026 the Labor Department proposes the rule [1]
   5. 29 October the rule is finalised [1]
   6. 1 July 2027 PBMs must start disclosing [2]

   Why it matters

   The department says lower costs should reach workers as well as their employers. [1]

   How it works

   Economists call this asymmetric information: one side of a deal knows more than the other. [1]

   Experts expect the rule to help mostly by pushing PBMs to compete harder. [1]

   The truth

   • What is really going on The US Labor Department is forcing PBMs, the drug middlemen whose three biggest firms handle about 80% of US prescriptions, to show employers every payment they collect. [1]
   • What is really going on Until now only the PBMs could see what they kept between the plan, the pharmacy and the drugmaker. [1]
   • Why it works on people A $22 billion saving sounds settled, but it is the department's own estimate, and the yearly figure STAT reports would add up to far less over ten years. [1][2]
   • PBMs stand to lose income that only they could see until now. [1]
   • Employers gain figures they can audit, and a reason to bargain. [1]
   • But with three firms holding 80% of prescriptions, an employer has few rivals to move to. [1]
   • Who gains Large employers that pay their workers' health bills — From July 2027 they can see and audit every payment their PBM receives. [1]
   • Who pays Express Scripts, Caremark and Optum Rx — They must show employers income they could keep out of sight until now, or face fines and lost contracts. [1]
   • Nobody knows yet

     How much the PBM rule will really save.

     The department puts it at $22 billion over ten years, while STAT reports officials' figure as more than $800 million a year, which comes to far less over a decade. [1][2]

   • Nobody knows yet

     Whether any saving reaches workers at the pharmacy counter.

     The rule hands the figures to employers, and nothing in it sets what a worker pays for a prescription. [1]

   • Nobody knows yet

     Whether PBM groups will take the rule to court.

     They argued the department has no legal power to demand these figures, and the rule does not start until July 2027. [1][2]

   What comes next

   The rule takes effect on 1 July 2027. [2]

1. 02

   Airlines push back on a US Ebola travel form

   What happened

   • The CDC, the US national disease agency, will require a new form from every air traveller. [4]
   • Passengers and crew must state they were not in Congo in the past 21 days. [4]
   • The Democratic Republic of Congo, in central Africa, is the centre of an Ebola outbreak. [4]
   • More than 5,000 people there have died since May, government figures show. [5]
   • Airlines for America, which speaks for big US airlines, called the plan unworkable. [4]
   • US border officers screened about 130 million air passengers in 2025. [4]
   • Fewer than 25,000 of them had a link to Congo, Airlines for America says. [4]

   Who is involved

   • Airlines for America speaks for United, American, Delta, Southwest
   • IATA represents over 370 airlines

   How it unfolded

   The CDC limited travel from Congo for foreigners in May, then for US citizens in July. [4]

   1. May limits for foreign travellers from Congo
   2. July limits extended to US citizens
   3. 3 November every traveller signs a form

   Why it matters

   The form falls on every traveller in order to find the few who were in Congo. [4]

   How it works

   Why a middleman who sees both prices can keep the gap

   Economists call it asymmetric information: when only the middleman sees what the buyer pays and what the seller gets, he can quietly keep what lies between.

   The twist

   A PBM can keep the gap between what a plan pays and what a pharmacy gets, because only the PBM sees both numbers. Once the employer sees them too, the gap becomes something the two can bargain over.

   The picture

   • Express Scripts, Caremark and Optum Rx80%
   • Every other PBM20%

   Step by step

   1. 1 An employer pays the PBM for each worker's prescription
   2. 2 The PBM pays the pharmacy, and collects rebates from drugmakers
   3. 3 Only the PBM sees all three sums
   4. 4 So the employer cannot check the gap the PBM keeps
   5. 5 The new rule makes the PBM show every sum, every six months

   The same force, elsewhere today

   Where this chain is also running, in today's other stories.

   • The US Ebola travel form

     The CDC cannot see where 130 million air passengers have been, so it makes each one write it down and sign.

   • The warning letter to Northland

     Only the drug maker saw its own germ tests, and the FDA found what they showed only by inspecting its records.

   Where you've seen this

   Used cars

   the seller knows the faults the buyer cannot see

   Health insurance

   the buyer knows their own health better than the insurer does

   Selling a house

   the agent sees every offer, and the owner sees only the ones passed on

   The catch

   Seeing the numbers lowers them only if the employer can switch to another PBM. Three PBMs handle about 80% of US prescriptions, so there are few rivals to switch to.

   And the whole of it

   A worker at the pharmacy counter sees only what they pay. The employer sees a bill, and the drugmaker sees the rebate it paid. Only the PBM sees all three, and from July 2027 employers will see them too.

   The truth

   • IATA, which represents over 370 airlines, said two weeks was too little time to prepare. [4]
   • IATA asked why ships and land crossings are left out of the rule. [4]
   • Who pays Airlines flying to the US — They must change check-in systems and train staff to collect a signed form from every passenger by 3 November. [4]
   • Nobody knows yet

     What the US Ebola travel form will catch.

     Fewer than 25,000 of the 130 million air passengers screened in 2025 had a link to Congo, and the CDC did not answer Reuters' request for comment. [4]

   What comes next

   The form becomes compulsory on Tuesday, 3 November. [4]

1. 03

   Pakistan finds its eighth polio case this year

   What happened

   • Pakistan confirmed its eighth polio case of 2026 on Sunday. [6]
   • The child is a girl of 13 months from Khyber district. [6]
   • Polio can paralyse a child for life; it has no cure, but vaccines prevent it. [6]
   • Pakistan and Afghanistan are the last two countries where polio has never stopped spreading. [7]
   • A round for nearly 24 million children in 97 districts starts today. [6]
   • It runs from 2 to 8 November, alongside a round in Afghanistan. [6]
   • Pakistan has run four large campaigns this year, reaching more than 45 million children. [6]

   How it unfolded

   In Karachi's District Central, about 4,000 workers used to walk 8 to 10 km a day. [7]

   Many skipped lunch to save their daily allowance of 1,500 rupees. [7]

   1. 2 November the round starts
   2. 8 November the round ends

   Why it matters

   The programme says no child is safe until every child is vaccinated, again and again. [6]

   How it works

   Epidemiologists test the environment for the virus; samples around Peshawar show it still circulates. [6]

   The truth

   • Some families refuse the drops because of rumours, and some turn violent, Dawn reports. [7]
   • Who gains Children in 97 districts of Pakistan — A vaccination round for nearly 24 million of them starts today, alongside one in Afghanistan. [6]
   • Who gains Polio workers in Karachi's District Central — They now get lunch and transport during campaigns, and the district says they have all returned this year. [7]
   • Nobody knows yet

     How widely polio is spreading around Peshawar and Khyber.

     Environmental samples there show the virus circulating, but the programme has given only the count of confirmed cases, eight this year. [6]

   Good news

   • The district now gives its workers lunch and rides in rickshaws that seat seven to nine. [7]
   • Its deputy commissioner, Taha Saleem, says the workers have all come back this year. [7]
   • In Karachi's District Central, polio workers now get lunch and a rickshaw ride during each campaign. The district's deputy commissioner says all of them came back to work this year.
   • Pakistan has run four large polio campaigns this year, reaching more than 45 million children several times over.
2. 04

   An Alzheimer's antibody fails its trial

   What happened

   • Acumen Pharmaceuticals, a US drug company, has stopped work on its Alzheimer's drug sabirnetug. [8]
   • The drug failed a phase 2 trial, the mid-sized test before a final one. [8]
   • After 18 months, thinking and daily skills declined about as fast as on a dummy drug. [8]
   • Neither dose tested, 35 or 50 mg for each kilogram of weight, slowed the decline. [8]
   • Sabirnetug is an antibody built to catch amyloid oligomers, small clumps of a protein. [8]
   • Acumen's shares fell 91% in a week, from $2.29 to 21 cents. [8]
   • The company says it will save cash and look at its options. [8]

   Why it matters

   Sabirnetug was Acumen's leading drug, so the failure leaves the company's future open. [8]

   How it works

   Trial designers call the main goal an endpoint: the one measure that decides pass or fail. [8]

   The truth

   • Its shareholders lost most of the stake's value in one week. [8]
   • Who pays Acumen's shareholders — The company's shares fell 91% in a week after its leading drug failed. [8]
3. 05

   FDA advisers weigh eye drops for children's short sight

   What happened

   • Sydnexis, a drug company, wants US approval for SYD-101, eye drops for children's short sight. [9]
   • Short sight, or myopia, blurs far-away things and worsens fastest in young children. [9]
   • The drops carry a tiny dose of atropine: 0.01%. [9]
   • In the main trial, children aged 3 to 14 used them for three years. [9]
   • Fewer children on the drops passed a set level of worsening than on dummy drops. [9]
   • The gap was 9.6 percentage points; the trial was planned to find 15. [9]
   • The company's case now goes to the FDA's outside advisers on eye and skin drugs. [9]

   How it unfolded

   The FDA, the US drug regulator, turned the drops down in October 2025. [9]

   It agreed the drops met their main goal, but called the effect modest. [9]

   Why it matters

   Worsening myopia in childhood cannot be undone, the company says, so slowing it matters. [9]

   How it works

   Statisticians call a gap significant when it is real, which is not the same as large. [9]

   The truth

   • The company says young children, whose eyes worsen fastest, gain more than the average suggests. [9]
   • Who gains Sydnexis — Its eye drops get a second hearing before the FDA's outside advisers after the FDA turned them down in October 2025. [9]
   • Nobody knows yet

     How the FDA's outside advisers will judge the myopia drops.

     The company's briefing papers are public, but we found no report of the advisers' meeting or of any vote. [9]

4. 06

   A gene edit lets two patients fast safely

   What happened

   • Beam Therapeutics, a US gene-editing company, reported early results for its treatment BEAM-301. [8]
   • It is for glycogen storage disease type 1a, a rare inherited liver disease. [8]
   • Patients' livers cannot release stored sugar, so they take starch to stop blood sugar crashing. [8]
   • Tiny fat bubbles carry the editor into the liver. [8]
   • Two of three patients on the 40 mg dose went the full 15 hours without food. [8]
   • The third patient showed no gain, perhaps because of body weight, Beam said. [8]

   How it unfolded

   Another gene therapy, Ultragenyx's Genglycos, became the first approved for the disease in August. [8]

   1. August Genglycos approved
   2. Now BEAM-301's first results

   Why it matters

   If the effect lasts, patients could live without their daily starch. [8]

   How it works

   Geneticists call BEAM-301 a base editor: it changes one letter of DNA, here R83C. [8]

   The truth

   • The results come from only three patients, with data cut off on 17 August. [8]
   • Nobody knows yet

     Why Beam's third patient did not respond.

     Beam points to body weight and to the patient carrying the R83C mistake on only one of its two copies of the gene, but three patients cannot settle it. [8]

   Good news

   • Both of those two patients stopped needing their daily starch. [8]
   • Two of the three patients given 40 mg of Beam's gene edit went the full 15 hours without food. Both stopped needing their daily starch.

   What comes next

   Beam is now testing a higher 60 mg dose. [8]

5. 07

   Novartis writes off $1.9 billion on a muscle drug

   What happened

   • Novartis, a Swiss drugmaker, will take a $1.9 billion charge on a muscle-disease drug. [11]
   • The drug, del-desiran, came with its $12 billion purchase of Avidity Biosciences. [11]
   • It failed a late-stage trial in August in a rare muscle-wasting disease. [11]
   • Novartis revealed the charge in its quarterly results on Tuesday 27 October. [11]
   • An open extension of the trial, where patients knowingly get the drug, is still running. [11]

   Who is involved

   • Novartis still hopes for approval

   How it unfolded

   1. August the trial fails
   2. 27 October the $1.9 billion charge

   Why it matters

   Novartis faces patents running out on big drugs, so it needs new ones like this. [11]

   How it works

   Accountants call the charge an impairment: it cuts what the company says the drug is worth. [11]

   The truth

   • Novartis still hopes to win approval, but has not said when a new trial would start. [11]
   • Who pays Novartis — It is writing off $1.9 billion of the $12 billion it paid for Avidity Biosciences. [11]
   • Nobody knows yet

     Whether del-desiran can still reach patients.

     Novartis expects to need another final trial and has not said when one would start. [11]

   What comes next

   Its executives told analysts they expect to need another final trial. [11]

6. 08

   FDA warns a scan-drug maker over germs

   What happened

   • The FDA sent a warning letter on 22 October to Northland Nuclear Medicine in Bismarck. [10]
   • Northland makes PET drugs, radioactive tracers used in a kind of medical scan. [10]
   • Inspectors visited in May and read its germ tests from the cleanest work areas. [10]
   • Records showed more than 100 such finds between March 2024 and April 2026. [10]
   • Of about 75 finds since December 2024, only two were sent off to be identified. [10]
   • Its test plates were stored with a spore-killing liquid, which can hide germs. [10]
   • Batches kept failing a yield limit, so the firm lowered the limit. [10]
   • The FDA said lowering a limit to fit a failing process breaks the rules. [10]

   How it unfolded

   1. May inspectors visit
   2. June the firm replies
   3. 22 October warning letter

   Why it matters

   Without knowing which germs grew, nobody can trace where the contamination came from, the FDA said. [10]

   How it works

   Quality engineers call this root-cause analysis: find why a fault happens, then fix that. [10]

   Only the drug maker saw its own germ tests, and the FDA found what they showed only by inspecting its records.

   The idea, in story 02: Why a middleman who sees both prices can keep the gap →

   The truth

   • The FDA said the firm has not reviewed whether past batches should have been released. [10]

   What comes next

   The FDA called the firm's June reply inadequate, and warned of seizure or a court order. [10]

7. 09

   Alzheimer's risk genes point to the brain's immune cells

   What happened

   • A study in Nature, a leading science journal, found 48 new genetic risk spots for Alzheimer's. [12]
   • It compared the DNA of about 109,000 people with Alzheimer's and 2.1 million without it. [12]
   • People in the study came from many different ancestries. [12]
   • The team found 118 risk spots across all groups, and 9 more within single ancestries. [12]
   • Genes more active in microglia, the brain's immune cells, carried much of the risk. [12]
   • So did genes less active in neurons, the brain's nerve cells. [12]
   • Common DNA differences account for about 16% of the differences in Alzheimer's risk. [12]
   • That is nearly three times earlier estimates. [12]

   Who is involved

   • Acumen's sabirnetug aimed at amyloid; failed

   How it unfolded

   Twin studies suggest genes explain 60% to 80% of Alzheimer's risk. [12]

   Why it matters

   Today's approved Alzheimer's drugs target only amyloid, and have shown limited benefit, the authors write. [12]

   Acumen's failed drug, reported this week, was also aimed at amyloid. [8]

   How it works

   Geneticists call this a genome-wide association study: compare DNA from many sick and healthy people. [12]

   The truth

   • Nobody knows yet whether drugs aimed at the new targets will work. [12]
8. 10

   Bacteria inside pancreatic tumours linked to longer survival

   What happened

   • Researchers found bacteria living inside pancreatic tumours, in a study in Cell Death & Disease. [13]
   • The cancer studied is PDAC, which grows from the pancreas's ducts. [13]
   • It used samples from 62 patients treated before surgery and 101 treated after. [13]
   • It also used mice bred to grow the cancer. [13]
   • Tumours held more kinds of bacteria than healthy pancreas tissue. [13]
   • In mice, a bacterial molecule increased autophagy, the way cells break down their own parts. [13]
   • Patients whose tumours had more bacteria and more autophagy lived longer. [13]

   Why it matters

   If the link holds, tumour bacteria could help doctors judge a patient's outlook. [13]

   How it works

   Epidemiologists call this an association: two things found together, without proof one causes the other. [13]

   The truth

   • The study shows a link, not that the bacteria themselves help patients live longer. [13]