Transformative PBM Reform Legislation Signed into Law
PBM Reform Legislation Signed into Law
President Trump signed a comprehensive spending bill incorporating landmark PBM reform legislation, ending a partial government shutdown while targeting pharmacy benefit managers (PBMs) with transformative changes. This PBM reform legislation prohibits PBMs from tying rebates to drug manufacturers’ list prices and mandates 100% pass-through of rebates to health plans and sponsors, eliminating incentives that favor high list prices over cost containment. As detailed in a MedPage Today report, pharmacists and stakeholders like the National Community Pharmacists Association (NCPA) praise these reforms for leveling the playing field, curbing pharmacy closures, and improving patient access.
Severing Rebate-List Price Links
The PBM reform legislation dismantles core PBM business models by breaking the connection between rebates and list prices, where PBMs previously kept portions of rebates from elevated drug prices, inflating costs. A Federal Trade Commission (FTC) analysis shows the three largest PBMs—CVS Health’s Caremark Rx, Cigna’s Express Scripts, and UnitedHealth’s OptumRx—inflated specialty generic drug prices for heart disease and cancer treatments, generating over $7.3 billion in revenue from 2017 to 2022 while over-reimbursing affiliated pharmacies. New rules require semi-annual PBM reports on drug spending, rebates, spread pricing, formulary rationale, and benefit design, plus stronger Centers for Medicare & Medicaid Services (CMS) enforcement for greater accountability in generic and biosimilar markets.
This PBM reform legislation will promote transparent pricing, lowering net drug costs, stabilizing formularies, and aid reimbursement for new therapies. It reduces barriers for independent pharmacies, fights “pharmacy deserts,” and sustains local access, per NCPA data. Standardized Medicare Part D reporting and CMS oversight could enable competitive pricing, influencing commercial payers. Groups like Transparency-Rx and the National Alliance of Healthcare Purchaser Coalitions call it a “game-changer” for competition and employer costs, despite PBM pushback—setting the stage for deeper industry shifts and outcomes research.
