PBMs Face Pressure to Stay Ahead of Policy Changes | PBMI 2025

Pharmacy benefit managers (PBMs) are under increasing pressure to anticipate state and federal policy changes, and proactive planning is quickly becoming the difference between smooth growth and expensive setbacks, according to Joe Boyle, president of ClearFile.

At the 2025 PBMI National Conference in Orlando, Boyle shared with Manage Healthcare Executive methods PBMs should take in responding to fast-moving policy changes that directly affect their business operations.

He explained that priorities typically depend on the size and location of a PBM’s membership base, as well as the financial risks tied to state-specific regulations.

“On an individual basis, I would prioritize it in a few ways, based on your number of lives, where your state, where you have the most membership in that state, is going to be your priority state, or, on the contrary, states that have the biggest fines and fees for repercussions,” he said.

This balancing act means PBMs should constantly reassess their compliance strategies.

According to Boyle, this cycle of “prioritizing, reprioritizing, reprioritizing” is now a significant focus in the industry. As regulatory requirements continue to evolve, simply reacting to new rules is no longer enough. Instead, PBMs are expected to anticipate changes and adapt quickly to avoid disruptions to both operations and member services.

Boyle shared an example of a PBM that is actively expanding across multiple regions while keeping compliance at the forefront.

“We work with one PBM that even as they're growing their business, their chief growth officer is joining our calls saying, ‘Hey, we're growing the business over here, north, south, east and west. We need to get licensed,’” he said.

He stressed that this type of leadership is essential for long-term sustainability.

“Being a proactive PBM is crucial, and like we're trying to help everybody get to that same spot,” he noted.

For Boyle, success lies in helping PBMs shift from reactive problem-solving to building forward-looking compliance strategies. This not only reduces regulatory risks but also creates a foundation for smoother growth in a marketplace that continues to face heightened scrutiny and policy changes at both state and federal levels.