Insights

On October 1, 2026, Judge Brian M. Cogan of the U.S. District Court for the Eastern District of New York denied NYP’s motion to dismiss a consolidated antitrust complaint brought by three self-funded union health plans. The ruling is significant for two reasons. First, it demonstrates that plaintiffs can successfully allege market power against hospital systems even in the absence of traditionally high market shares. Second, the court’s reasoning closely tracks the arguments advanced by the DOJ in its Statement of Interest filed in the case: that market power need not be established through market share alone and can be shown through direct evidence such as supracompetitive pricing, and that exclusionary conduct and rival foreclosure are not required elements of a Section 1 claim. The recent decision validates the government’s legal theories and could enhance the viability of the DOJ’s parallel action against NYP, which is currently proceeding in the Southern District of New York.

In June 2026, federal regulators and lawmakers continued their efforts to improve drug affordability through targeted reforms. These recent developments will primarily impact pharmaceutical manufacturers, managed care organizations, and pharmacy benefit managers (PBM) serving Medicare Part D program members. PBMs, Medicare Advantage organizations, and Part D sponsors should monitor these changes in the interest of maintaining compliance and providing input on regulatory proposals that may influence their business operations or compensation structures in the future.

Two significant recent developments illustrate the Trump administration’s increasing focus on policing of hospital contracting practices that limit health plan network design flexibility. On June 16, 2026, the U.S. Department of Justice (DOJ) Antitrust Division and Ohio attorney general filed a proposed consent decree resolving their civil antitrust suit against OhioHealth. (Prior Alert) Two days later, the White House Council of Economic Advisers (CEA) released a memorandum quantifying the potential economic effects of a broader ban on the types of contracting restrictions at issue in the OhioHealth case and the DOJ's parallel suit against NewYork-Presbyterian. This alert updates our prior coverage of the OhioHealth complaint and summarizes both developments.

On April 10, 2026, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule (2026 CMS Interoperability Standards and Prior Authorization for Drugs, or CMS-0062-P) outlining the agency’s plans to impose new interoperability requirements on payors participating in certain Medicare and Medicaid programs. As described by the agency in a recent press release, the proposed rule “builds on” prior rulemaking by clarifying and enhancing interoperability requirements for payors’ prior authorization processes, specifically those associated with coverage requests for pharmaceutical therapies.

As pharmaceutical weight-loss therapies have surged in popularity, health plans, regulators, and courts have found themselves grappling with a set of increasingly pressing and complex questions: who must cover these drugs, under what circumstances, and for whom?

On February 20, 2026, the Department of Justice’s Antitrust Division (DOJ) and Ohio Attorney General (Ohio AG) sued OhioHealth Corporation (OhioHealth), alleging that OhioHealth had unlawfully restrained trade in the market for general acute care inpatient hospital services in the Columbus metropolitan statistical area and the narrower Central Columbus area, respectively. The DOJ and Ohio AG allege violations of Section 1 of the Sherman Act, as well as the Valentine Act (Ohio’s antitrust statute), claiming that OhioHealth leveraged its market power to impose contractual restrictions that blocked payors from working with competing health systems to design “budget-conscious” lower-cost health plans.

By the end of 2025, 16 drug manufacturers had voluntarily negotiated and executed agreements to adopt Most Favored Nation (MFN) pricing for certain high-cost drugs. The Trump Administration highlighted the agreements in its “Great Healthcare Plan,” published on January 15, 2026, and communicated the government’s plans to “codify” such deals as a means of “get[ting] Americans the same low prices that people in other countries pay.” The Administration recently leveraged MFN pricing to establish the TrumpRx website, which helps uninsured or cash-paying consumers find drugs at a discounted price. The website reflects the Administration’s stated commitment to provide more lower-cost drugs directly to consumers. Currently, 40 branded medications are available at reduced prices.

On February 3, 2026, President Trump signed a $1.2 trillion spending deal that, among other points, introduced significant regulatory changes for Medicare Part D plans and PBMs providing services to PDP sponsors in the Medicare Advantage and Medicare Part D programs, and imposed significant new restrictions and transparency requirements on PBMs contracting with private group health plans.

The deadline for Department of Health and Human Services (“HHS”) to notify approved manufacturers of acceptance into the 340B Rebate Model Pilot Program has passed, and stakeholders across the healthcare industry should start planning for compliance and operational changes. The Model Pilot Program may also face legal challenges that could delay or disrupt implementation.

On May 12, 2025, President Trump issued an Executive Order titled "Delivering Most-Favored-Nation Prescription Drug Pricing to American Patients," which aims to reduce the costs of prescription drugs and biologics for American consumers and other payers. This Order revives a plan from President Trump’s first term and follows his April Executive Order, “Lowering Drug Prices by Once Again Putting Americans First,” which also sought to reduce drug prices. With drug prices in the United States nearly three times higher than many other countries, this second Order asks drug manufacturers to adopt Most-Favored-Nation (MFN) pricing for drugs sold in the United States or face potential regulation. MFN pricing would tether drug prices offered in the United States to the lower-cost prices offered in other comparably developed nations, such as Canada, Germany, or the United Kingdom.

On April 17, 2025, Arkansas recently became the first state to enact broad restrictions on pharmacy benefit managers (“PBMs”) owning retail pharmacies within the state.