How PBMs Need to Respond to Government Policy Changes: More Lawyers, More Partnership, Lots of Flexibility | PBMI 2025

With state and federal legislators and regulators casting a wider net of new laws and regulations over the pharmacy benefit management industry, pharmacy benefit managers (PBMs) need to get more involved in lawmaking, recruit allies, stay flexible and informed — and hire more lawyers, according to members of a panel about how PBMs are responding to government policy changes at the 2025 Pharmacy Benefit Management Institute Annual National Conference in Orlando, Florida.

“If your legal department consists of someone who used to be your best implementation coordinator, that's not going to cut it anymore,” said Eric Barker, chief health strategist officer at True Rx, a pharmacist-owned PBM headquartered in Washington, Indiana. “You need experts; you're going to need attorneys and compliance experts. It's really important.”

Another panelist, Mark Campbell, Pharm.D., chief pharmacy officer for RxBenefits, said his company had increased its legal staff from one pharmacist in 2017 to eight lawyers on staff or under contract “because that’s what it takes to keep up.” RxBenefits, based in Birmingham, Alabama, bills itself as a pharmacy benefits optimization firm.

Barker, Campbell and the two other panelists, Robyn Crosson, J.D., vice president of government relations at Navitus Health Solutions, a PBM in Madison, Wisconsin, and Joe Boyle, president of ClearFile, a regulatory consulting and software company in Hartford, Connecticut, touched on a wide range of topics. They did not discuss any particular law or regulation in detail, focusing instead on advice about how PBMs should adapt to regulatory and policy changes, much of it occurring on a state-by-state basis in the absence of major PBM legislation at the federal level. In addition to the need for lawyers and experts, the throughlines in the conversation ranged from recommendations to be proactive with legislators and regulators to taking a more tailored approach to clients to maintaining an overall readiness to adjust and change as new laws and policies get implemented.

“I mean, the reality is, in the time when you're out doing a call or working to get a new client, the state just passed a bill that said, ‘Oh, you can't actually do that utilization management that you planned on,’” said Crosson. “So you're constantly just having to be flexible, stay in the know, from everything from your programming to how you're actually pricing things to your disclosures and everything else. You've just got to be constantly aware and kind of just expect it. It's a roller coaster.”

Barker referenced the legal challenge that has blocked for now the implementation of Arkansas’ law that prohibits PBMs from operating pharmacies. “So you got to keep track of things. Heaven forbid you have an employer who lives with people in multiple states where each person has a different set of rules,” he said.

Many of the topics discussed by the panel stemmed from the fact that legislative and regulatory action involving PBMs has devolved the states. Congress was on the brink of passing federal PBM legislation late last year as part of a large spending bill, but it was stripped out along with many other provisions in a flurry of last-minute maneuvering fueled in part by Elon Musk’s objections package. The One Big Beautiful Bill Act that President Donald Trump signed into law on July 4 also lacked any provisions affecting PBMs. In an interview after the session, Crosson expressed optimism about federal legislation this fall. During the session, Barker said it would be helpful if federal lawmakers would settle on one or two of the different bills that have been proposed. PBMs have become a favorite political target, he noted. “Amazingly, this is the one thing the left and right agree on. They all hate PBMs,” Barker said.

Back to basics

Campbell observed that state and federal policy changes are aimed at PBM business practices that have evolved over decades. He said it is going to take time to adjust for both large and small PBMs to comply with the new regulations, which in many cases can’t be taken at face value.

“We've been buying just based off of rates and rebates,” he noted. “Now we're trying to buy off of net cost, which is the way to go. All these laws are trying to direct us in that approach, but untangling all the complexities that we've built over the last 40 years will take a little bit of time.

“It's tough to be an employer right now, and it's tough to help employers understand how to navigate these channels,” he said.

Campbell also mentioned other forces that are roiling the PBM sector, such as the introduction of biosimilars to Humira (adalimumab) and Stelara (ustekinumab). Clients, he said, “want to get the maximum amount of value that they can for their members and for themselves” and are looking for options that aren’t on the table for them today that suit their particular needs. “The cookie-cutter model is not going to work for employers moving forward,” he said.

But Campbell also had a back-to-basics message. He said there should be a comprehensive strategy for managing discounts and that PBMs shouldn’t “chase” rebates. Campbell drew a comparison to bass looking at shiny lure. He cautioned against single-minded pursuit of the best price as potentially burdening employers and the members with “layers of complexity.”

Campbell said PBMs have a responsibility to “build their formularies based on what makes sense.” Some expensive drugs shouldn’t be on formularies because they don’t have evidence of having achieved good clinical outcomes. Others shouldn’t be on because of lower-cost alternatives, he said. “Just reduce the number of choices to what makes good practical sense economically and clinically, and that will alleviate a lot of the strain on the system,” Campbell said.

Transparency is a buzzword in the PBM industry, but Crosson noted the reporting requirements that go with it may be unexpected. The requirements are “brutal” in multiple states, she said, and are tied not just to initial licensure but also to renewals. Crosson also mentioned the importance of documenting processes.

She agreed with other panelists about getting into the trenches of lawmaking but stressed the importance of partnering with clients who are employers. “They’re members of the community, and that matters a lot more than you walking in and [speaking] from a PBM perspective.”

Crosson said it is also important to work with regulators. “Used to be you would hide in a corner and be like, ‘Oh, okay, they didn't notice me.’ Instead, you need to get out in front of it. If these laws are new to them, too, they don't have to implement them any better than we do. So if you have an idea, if you have a way to streamline, if you have a way to make it less painful for both them and you and your clients and the patients, then bring those forward to them as they're writing the regulations, as they're writing the rules. If you can get in front of it, it's better.”