FAQ: What managed care leaders should know about PBM reform in 2026

Pharmacy benefit managers (PBMs) remain at the center of growing policy scrutiny, as lawmakers, regulators and employers push for greater transparency and accountability in prescription drug pricing. A mix of new laws, regulations and industry pressure is starting to change how PBMs operate — and what that could mean for payers, providers and patients.

1. What is driving renewed attention on PBM reform in 2026?

PBMs have faced increasing scrutiny over their role in drug pricing, reimbursement practices and overall healthcare costs. Policymakers from both parties are advancing proposals targeting transparency, rebate structures and contracting practices.

Industry experts have said the pace of change is accelerating. In fact, Jeffrey Hogan, managing director and co-founder of Judi Group, said during a recent Managed Healthcare Executive webinar that he has “never seen as much activity, particularly in the courts and federal legislation and state legislation focused specifically on pharma and particularly on PBMs.”

FAQ 2. What do PBMs do in the drug supply chain?

PBMs act as intermediaries between insurers, pharmacies and drug manufacturers. They design formularies, negotiate rebates and manage drug utilization.

Stacie B. Dusetzina, Ph.D., professor of health policy and cancer research at Vanderbilt University Medical Center, told MHE that PBMs play a role as an intermediary in the prescription drug supply chain.

“(PBMs) work to design formularies — what is covered and how much it will cost for patients when they fill it,” Dusetzina said. “They also negotiate for lower drug prices with drug manufacturers and manage drug spending. This can mean that they set prices and access rules in ways that discourage use of some drugs over others.”

FAQ 3. How do PBMs influence what patients pay at the pharmacy counter?

PBMs directly affect out-of-pocket costs through formulary design, tier placement and cost-sharing structures.

According to Dusetzina, PBMs set prices and access rules in ways that discourage use of some drugs over others, which can steer patients toward preferred medications but may also limit access depending on coverage rules.

FAQ 4. Do PBMs help lower drug costs or contribute to higher spending?

The answer is both, and that complexity is at the center of the policy debate.

“PBMs have a complex role,” Dusetzina said. “On one hand, they serve as the negotiator that helps to get lower prices on covered prescription drugs. This is a valuable role and the large size and negotiating power from bigger PBMs help them to get large discounts and rebates from drug companies.”

However, she added that PBMs add some costs to the system by the fees they charge for their services.

“Some argue that the costs of their services are too high for the benefits that they provide, though there is virtually no transparency into these systems, making it hard to evaluate the savings they produce and the costs that they add,” she said.

FAQ 5. Why is transparency such a major issue in PBM reform?

A lack of visibility into pricing, rebates and fees has made it difficult for policymakers and payers to evaluate PBM performance.

Dusetzina noted that there is virtually no transparency into these systems, making it hard to evaluate the savings they produce and the costs that they add.

Recent policy changes are beginning to address these concerns. The Consolidated Appropriations Act of 2026 requires full rebate pass-through, plan sponsor audit rights and detailed cost reporting. This act gives employers and regulators new tools to evaluate PBM compensation and performance.

Hogan mentioned in the webinar that PBMs have historically operated as a “black box of opacity” for employers, making it difficult to determine whether they are helping or increasing costs.

FAQ 6. What policy changes are being proposed to improve transparency and accountability?

Current reforms focus on increasing reporting requirements, limiting certain pricing practices and strengthening oversight.

Dusetzina expressed that legislative efforts should be made to have full transparency into the supply chain for public payers, such as Medicare and Medicaid, so independent reviews could be conducted to understand all entities included in pharmacy transactions.

“Without this, legislation to limit a certain type of fee will likely not be very effective,” she said.

Regulatory action is also playing a role. For example, Federal Trade Commission actions involving Express Scripts and CVS Caremark — along with a pending case involving Optum Rx — are pushing the industry toward a more transparent, “fiduciary PBM” model focused on rebate pass-through and clearer financial reporting, according to the webinar.

FAQ 7. Why is it difficult to ensure PBM reforms lower patient costs?

Even well-intentioned reforms do not always translate into savings at the pharmacy counter.

This is challenging because PBMs have a dual role as negotiators that are lowering prices and as entities that make profit off drug sales, according to Dusetzina.

This structure can create competing incentives that complicate efforts to directly reduce patient costs.

FAQ 8. How could PBM reforms affect access to specialty and high-cost drugs?

The impact remains uncertain, particularly for high-cost therapies such as oncology drugs.

“It is not clear to me yet how beneficial the proposed reforms will be,” Dusetzina said. “Prior efforts to pass through rebates and other changes targeting how PBMs are paid have not been successful or have been estimated to increase spending.”

This uncertainty raises questions about how reforms could influence coverage decisions, utilization management and patient access.

FAQ 9. What broader changes are happening in the PBM and pharmacy marketplace?

Experts say the industry is moving toward a more transparent and accountable model, driven by policy changes and market pressure.

Chad Worz, Pharm.D., executive director and CEO of The American Society of Consultant Pharmacists, also said in the webinar that recent reforms are not incremental and directly address contracting practices that have historically pressured pharmacies.

In addition, increased transparency and new data tools are enabling employers and patients to better understand drug costs, while new market entrants are offering alternative pricing models that emphasize simplicity and accountability.

FAQ 10. What should managed care leaders be watching next?

Based on the expert insights, leaders should monitor how new laws, regulatory actions and market changes evolve over the next several years.

Key areas to watch include transparency rules, rebate prices, fiduciary standards and how changes could affect programs such as Medicare, Medicaid and 340B.

As pharmacy costs continue to rise — and make up a larger share of total healthcare spending — PBM reform is likely to remain a major issue for managed care organizations.

This FAQ was approved for accuracy by Dusetzina.