The Trump administration is pressing forward with Most Favored Nation drug pricing — the policy that would require drug manufacturers to charge American payers no more than what comparable countries pay. [1] The idea is elegant. The execution is a fight.

MFN pricing, in its simplest form, benchmarks US drug costs against an index of international prices. If France pays $200 for a course of treatment and the US pays $800, MFN would close that gap. The administration has been advancing MFN through mandatory Medicare demonstration models — including programs called GLOBE and GUARD — that would apply to both Part B and Part D drugs. [2] Congress has been asking pointed questions about how far the executive branch can push this without legislation. A March hearing produced coordinated oversight from both chambers. [3]

The pharmacy benefit managers — the opaque intermediaries who negotiate drug prices between manufacturers and insurers — are pushing back hard. PBMs control the formulary decisions that determine which drugs patients can access and at what cost. An FTC investigation found that PBM practices are driving higher drug costs and producing conflicts of interest. [4] A landmark FTC settlement with a major PBM mandated sweeping changes, including delinking PBM compensation from drug prices.

The PBM industry's argument against MFN is that international price benchmarking will reduce manufacturer investment in new drugs, ultimately harming American patients. The counterargument is straightforward: the current system produced a country where drugmakers raised US prices on at least 350 brand-name medications at the start of 2026, including vaccines against COVID, RSV, and shingles, even as the administration was publicly vowing to cut costs. [5]

Meanwhile, the first round of Medicare drug price negotiations — the ones authorized by the Inflation Reduction Act, not the Trump MFN program — produced negotiated prices for ten medications that took effect January 1. [6] Those prices represent minimum discounts of 38 percent off 2023 list prices. A second round of 15 additional drugs is in negotiation, with prices effective in 2028.

The patient sitting in a pharmacy today exists at the intersection of three systems: a negotiation program that is working but slow, an MFN program that is ambitious but contested, and a PBM structure that profits from the complexity it was supposedly built to manage.

Something will give. The question is whether it gives in the direction of the patient.

-- NORA WHITFIELD, Chicago