Health

The rising cost of prescription drugs in the United States remains a pressing issue for many Americans. Recent polling by the Kaiser Family Foundation (KFF) indicates strong public support for various strategies aimed at reducing these costs. This concern has prompted both federal and state legislators to prioritize reforms in drug pricing. Notably, the Trump administration initiated efforts to tackle drug costs through regulatory actions and partnerships with pharmaceutical companies. Meanwhile, the Biden administration’s Inflation Reduction Act of 2022 enabled the federal government to negotiate prices for certain Medicare drugs, projecting a significant reduction in the federal deficit.

Amid these efforts, pharmacy benefit managers (PBMs) have emerged as key players in the drug pricing landscape, attracting scrutiny for their role as intermediaries between drug manufacturers and health insurers. Critics argue that PBMs contribute to rising drug prices due to their opaque business practices and market dominance.

In February 2026, Congress passed crucial reforms related to PBMs as part of the Consolidated Appropriations Act. These provisions aim to enhance transparency and accountability within the PBM sector, directly influencing how prescription drug costs are managed and negotiated in the U.S.

The Role and Function of PBMs

Pharmacy benefit managers serve as intermediaries in the pharmaceutical supply chain, negotiating discounts and rebates with drug manufacturers for insurance companies, including employer health plans, Medicare Part D, and Medicaid. PBMs manage pharmacy benefits by processing claims, reimbursing pharmacies, and structuring pharmacy networks. They also play a significant role in formulary design, which involves determining which drugs are covered by insurance plans and at what cost.

According to the Federal Trade Commission (FTC), three major PBMs—OptumRx, Express Scripts, and CVS Caremark—dominate the market, managing about 79% of all prescription claims for over 270 million people in the U.S. In 2023. This consolidation raises concerns regarding competition and market fairness.

Concerns Surrounding PBM Practices

Several practices within the PBM industry have drawn criticism, particularly regarding their impact on drug prices:

• Rebate Negotiations: PBMs often negotiate rebates with manufacturers, which can lower costs for health plans but may prioritize higher-priced drugs that yield larger rebates. This practice can inflate drug prices across the board, affecting patients who pay based on list prices.
• Spread Pricing: This controversial practice involves PBMs charging insurers a higher price for drugs than what they reimburse pharmacies, keeping the difference as profit. It has led to increased costs for insurers and financial strain on pharmacies.
• Lack of Transparency: Financial arrangements between PBMs and manufacturers are typically not disclosed, limiting the ability of plan sponsors to assess how much PBMs are actually paying for drugs on their formularies.

Federal Reforms and Legislative Changes

The PBM-related provisions enacted in February 2026 include several significant reforms aimed at improving accountability:

• Delinking Compensation: PBM compensation for services under Medicare Part D will no longer be tied to drug prices or rebates, shifting to a flat service fee starting January 1, 2028.
• Increased Transparency: PBMs will be required to report detailed data on drug utilization and pricing to plan sponsors and the Department of Health and Human Services (HHS) starting July 1, 2028.
• Reinforcing Pharmacy Access: Medicare plans must ensure contract terms are reasonable, allowing any willing pharmacy to participate in their networks.
• Passing Through Rebates: PBMs must pass 100% of negotiated rebates to employer health plans regulated under ERISA, promoting cost savings for employees.

These reforms aim to address the lack of oversight and transparency in PBM operations, providing federal and state regulators with better tools to monitor their practices.

Impact and Future Implications

While the Congressional Budget Office (CBO) estimates that these reforms could reduce the federal deficit by approximately $2.1 billion over the next decade, the long-term effects on drug pricing remain to be fully realized. The legislation does not address certain Medicaid-related provisions, which may continue to influence the overall cost structure of drug pricing.

ongoing scrutiny from federal agencies like the FTC has led to legal actions against PBMs for allegedly inflating drug prices, particularly for insulin. Settlements may require PBMs to adopt more transparent pricing structures, which could benefit consumers directly by lowering their out-of-pocket costs.

As the regulatory landscape evolves, stakeholders—including health insurance companies, PBMs, and consumers—will need to stay informed about how these changes may affect prescription drug pricing and accessibility. The coming years will be crucial in assessing whether these legislative efforts succeed in curbing the rising costs of medications.

As discussions around PBMs and drug pricing continue, public feedback remains vital. Readers are encouraged to share their thoughts and experiences regarding prescription drug costs and PBM practices.

Disclaimer: This article is for informational purposes only and does not constitute medical or financial advice.