Americans pay roughly 3x more for brand-name prescription drugs than people in comparable wealthy countries. The Trump administration has made it a top priority to combat this through Most Favored Nation (MFN) drug pricing, a model that pegs what Americans pay for drugs to the lowest or 2nd-lowest price paid by comparably developed countries. On May 12, 2025, Trump signed an Executive Order directing his administration to aggressively pursue MFN pricing on both a direct-to-consumer level and within Medicaid and Medicare. In the year since, the administration has rolled out TrumpRx and 3 CMMI Center for Medicare and Medicaid Innovation (CMMI) models: GENEROUS, GLOBE, and GUARD. This blog examines the intricacies of these initiatives and the remaining questions around overlap, participation, and transparency.
TrumpRx
The centerpiece of Trump’s drug pricing rollout is a portal comprised of opaque deals with 17 drug manufacturers. Announced in September 2025 and launched on February 6, 2026, TrumpRx is a direct-to-consumer comparison portal for cash-paying, uninsured Americans. The site routes patients to discounted brand-name drug prices and connects users to GoodRx, Cost Plus Drugs, and Amazon Pharmacy for generics, though it does not directly fill prescriptions itself.
Trump signed the 1st MFN deal with Pfizer in September 2025, and 16 other manufacturers have signed on since. In exchange for Section 232 tariff exemption, each agreed to participate in TrumpRx, offer MFN pricing to state Medicaid programs, and invest in U.S. manufacturing infrastructure and/or research and development. Infrastructure commitments have ranged from $10 billion from Boehringer Ingelheim to $100 billion from AbbVie, but with the agreements shielded from public view, it is impossible to assess whether the figures represent new investment or repackaged spending.
GENEROUS
Building on the TrumpRx deals, the Centers for Medicare and Medicaid Services (CMS) announced the Generating Cost Reductions for U.S. Medicaid (GENEROUS) model in late 2025 as the Medicaid arm of the Executive Order. The model benchmarks Medicaid drug prices against international comparators, with participation voluntary for both states and manufacturers. The model launched in January 2026 on a rolling basis as states and manufacturers continue to apply.
Following the April 2, 2026 announcement of increased Section 232 tariffs, CMS extended the manufacturer application deadline to June 11, 2026, citing an opportunity for small and mid-sized manufacturers to participate, while states now have until September 10, 2026 to apply. CMS claims overwhelming manufacturer interest but has yet to disclose which states or manufacturers have signed participation agreements. The only manufacturers known to be participating in GENEROUS are those who have already signed deals with the administration.
GLOBE and GUARD
The mandatory counterparts to the voluntary MFN framework, GLOBE (Global Benchmark for Efficient Drug Pricing) and GUARD (Guarding U.S. Medicare Against Rising Drug Costs), were announced in December 2025. GLOBE applies to Medicare Part B and runs from October 1, 2026 through October 1, 2031, while GUARD applies to Medicare Part D and runs from January 1, 2027, through December 31, 2031. Both extend through 2033 for rebate invoicing and reconciliation. Under both models, manufacturers pay rebates when drug prices exceed international benchmarks, with the explicit goal of lowering out-of-pocket costs for Medicare enrollees.
Unlike GENEROUS, participation is mandatory for all manufacturers of high-spend, single-source drugs and biological products, making GLOBE and GUARD the most structurally significant of the four initiatives.
Despite the mandatory framework of GLOBE and GUARD, questions remain about the participation of manufacturers who signed TrumpRx deals. There are no formal exemptions for them in the proposed rules, but concerns have been raised that these manufacturers may be exempt. If true, the voluntary deals would function not just as a pricing mechanism, but as an escape from the mandatory models.
How the Pricing Works
The pricing methodology compounds the problem, as the four initiatives use different strategies. TrumpRx and GENEROUS benchmark against the second-lowest price among G7 countries, Denmark, and Switzerland, adjusted by GDP per capita. Under GENEROUS, manufacturers are also required to self-report country-specific net prices to CMS, a feature that effectively redefines MFN as the second-lowest country-specific net price rather than the lowest visible list price.
GLOBE and GUARD offer two calculation methods, with CMS applying whichever produces the higher benchmark. Under Method I, CMS calculates the lowest country-level average price across 19 Organization for Economic Co-operation and Development (OECD) reference countries, adjusted by GDP per capita. Under Method II, manufacturers voluntarily submit their own across-country average net prices, which CMS then adjusts the same way. Because Method II produces a volume-weighted average rather than the single lowest price, it tends to yield a higher benchmark than Method I, meaning manufacturers who self-report are subject to a less favorable calculation. The structure is designed to incentivize disclosure, but it also means the benchmark patients benefit from depends on whether manufacturers choose to participate in a process that typically works against them, an uncertain foundation for a pricing model.
What Congress Is Saying
Despite broad political acknowledgment that Americans pay too much for prescription drugs and strong voter support for codifying MFN, MFN pricing has failed to generate consensus anywhere on Capitol Hill.
Democrats have primarily focused on concerns about a lack of transparency. On March 3, 2026, Senate Finance Ranking Member Ron Wyden (D-OR) and six Democratic colleagues wrote to 11 manufacturers demanding disclosure of which drugs are covered, the MFN price for each, and whether those prices undercut existing Medicaid net pricing. Senator Wyden has also worked with the ranking members of House Committees with jurisdiction over health care to send letters to the Department of Health and Human Services (HHS) and Merck requesting qualifying drug lists, pricing agreement disclosures, and benchmark calculations. In addition to the letters, Senate Democrats introduced S. 4355 demanding HHS release the deal documents.
Republican, for their part, are not aligned on MFN:
- At an April 22, 2026 Senate Finance hearing, Sen. Tillis (R-NC) dismissed the deals as a “simplistic” answer to a complex problem.
- Rep. Mast (R-FL-21) has actively championed them as recently as May 20, 2026, saying MFN is a “chance for our communities to finally get some relief.”
- H.R. 7837, the Most Favored Patient Act, introduced by Rep. Meuser (R-PA-9), would mandate MFN pricing for manufacturers who decline voluntary agreements by December 2028, and has not attracted any cosponsors as of June 22, 2026.
- Reps. Luna (R-FL-13) and Biggs (R-AZ-03) joined Reps. Kaptur (D-OH-09) and Khanna (D-CA-17) to introduce the Global Fairness in Drug Pricing Act, which would codify Trump’s deals into permanent law.
On June 2, 2026, CMS Administrator Dr. Oz acknowledged that without congressional action, the MFN deals expire when the administration does, a vulnerability the administration itself has been forced to concede. Days later, TrumpRx announced an expansion to more than 800 drugs, scaling a program whose durability is still unresolved.
What Stakeholders Are Saying
The debate over MFN pricing has exposed a striking disconnect: voters overwhelmingly want lower drug prices, but the policies designed to deliver them have drawn sharp opposition from the very groups meant to benefit.
A June 2025 national poll commissioned by the Pharmaceutical Reform Alliance captured just how urgent the issue feels to ordinary Americans. Conducted by Republican pollster Adam Geller, the survey of 1,000 registered voters found that 51% had difficulty affording prescriptions, 84% held the pharmaceutical industry most responsible for high prices, and 85% supported “America First” reforms to align U.S. drug prices with the lowest prices paid internationally. That frustration has translated into broad political support: 78% of voters backed President Trump’s May 12th Executive Order, including 61% of Democrats.
But public appetite for change has not meant public confidence in these specific policies. That gap shows up most clearly with TrumpRx. A Fortune analysis found that even discounted prices would remain out of reach for low-income patients, and that the portal’s digital-only design effectively locks out elderly, rural, and offline users, precisely the populations the broader effort claims to help. The program may ultimately serve a narrow slice of users who are uninsured, tech-savvy, and cash-ready, functioning less as a check on rising prices than as cover for them.
The Alliance for Aging Research raised the alarm early, warning that both GLOBE and GUARD would tie Medicare drug payments to prices set by foreign governments. The Alliance pointed to CMMI’s own projections showing the GLOBE model alone would increase healthcare costs for seniors by $3.6 billion. The Partnership to Improve Patient Care took the critique further, arguing that importing foreign price controls means importing the QALY frameworks those systems use to assign value to human life, the same formulas Medicare has explicitly banned over concerns about discrimination against elderly and disabled patients. The GLOBE and GUARD proposed rules drew over 20,000 comments during their public comment period, with sentiment running overwhelmingly negative, commenters characterizing both models as policies more likely to restrict access than deliver savings.
Conservative groups echoed those objections. On February 12, 2026, Americans for Tax Reform and more than 50 allied organizations urged Congress to reject codification of the deals, arguing that tariff-backed pricing concessions are government price controls by another name.
The Bottom Line
The administration has built an ambitious two-track MFN framework, but both tracks share the same vulnerability. The voluntary deals depend on a political priority that can change, and a tariff threat that can be lifted, and without congressional action, they expire with the administration. The mandatory models have structural teeth, but if manufacturers with White House agreements can claim exemption from GLOBE and GUARD, the framework loses its most consequential targets. What connects both problems is transparency. The agreements are private, the benchmarks rely heavily on manufacturer self-reporting, and the savings are unconfirmed. Until these things change, it is impossible to assess whether this framework represents a durable shift in drug pricing policy or simply the appearance of one.