States push for new PBM reporting rules | PBMI 2026

Legislative and regulatory changes at the federal level are bringing new reporting requirements to the forefront. The Consolidated Appropriations Act 2026, the first new federal legislation in 20 years to address pharmacy benefits, requires reporting of drug pricing, rebates, pharmacy reimbursement and benefit design structure. The Department of Labor has proposed similar roles for ERISA plans.

But that hasn’t stopped the states from putting forth their own laws and regulations related to PBMs, pharmacies and drug coverage. State proposals are targeting prior authorization, mandated coverage, formularies, biosimilar substitution, point-of-sale rebates, pharmacy reimbursement, and pharmacist scope of practice. These efforts aim to provide oversight and transparency, as well as increased access for patients.

These state laws, however, bring compliance, administrative and technology challenges to PBMs to ensure they meet all of the state reporting requirements, said speakers at a session at the annual meeting of the Pharmacy Benefit Management Institute in Orlando.

“We’re going to see a lot of regulations on how to report," said Robyn Crosson, J.D., VP of Government Relations at Navitus Health Solutions. “PBMs have to know where their data is and how to pull it because your rebate data are not in the same place as your claims data.”

One thing that the states, Crosson said, are asking for is reporting on prior authorization statistics, including how many prior authorizations were appealed and how many lost and won on the appeal. Efforts to reform prior authorization were active last session, and she expects to see additional regulations going forward.

“Prior authorization is a hot target,” she said. “We’re seeing bills that are saying mental health medications should not have any prior authorization. And a bill in Pennsylvania just was dropped the 18th of August that says PBMs have to pay for all FDA-approved Alzheimer's medications or treatments, with no step therapy. Cancer is another area where states are considering exempting medications from prior authorization.”

In fact, 45 states have rules or laws that address prior authorization, and 39 states have restrictions on utilization reviews, Navitus officials said.

Crosson said she expects there are more state efforts to freeze formularies, where PBMs would not be able to make formulary changes during of the plan year. “This could be really costly,” she said, pointing to Navitus’s effort to move people from Stelara to a biosimilar, which saved clients $120 million.

Panelist Grant Wallace, who manages benefits for the state of Arkansas, said one-size-fits-all solutions don’t work for members and sponsors. “You lose the ability for nuance and doing the appropriate thing for the member,” he said. “Every instance is very unique. Every drug interaction is very unique. Every patient is very unique, and I think that gets missed when you try to engage in public policy.” Wallace is director of the Employee Benefits Division and the Office of Property Risk for Arkansas.

Federal effort to watch

Panelists at the meeting also spoke about a federal effort to bring price transparency to consumers through The Patients Deserve Price Tags Act, a proposed law by Congress. Crosson said there are two versions, but the goal is to allow consumers to access drug prices at various facilities. One version of the bill includes a hold harmless provision, which could present some challenges because drug pricing is fluid, Crosson said.

“The hold harmless would say that if patients were shown a price of $15 at Walmart, but when they get to Walmart now it’s $18, the patient would pay $15, and the employer would pay $3,” she said. “But we could be dealing with a GLP-1 drug or a drug that has a $50 difference. That will add it up. That’s the biggest and scariest issue.”

Crosson said the bill is an effort to have price checks that drive responsible behavior and force people to show where the money is being spent. “But that part of the act is dangerous. For plan sponsors and for PBMs, this might change the way people are contracting.”

The Patients Deserve Price Tags Act also changes the narrative for pharmacies, Sharon Faust, Pharm.D., senior VP, Chief Pharmacy at Navitus Health Solutions, said during the session. “Pharmacies are more of a consumer-driven dynamic where lower prices attract consumers, and regulation may prevent them from doing that.”

For PBMs, Faust pointed out that if they aren’t able to simultaneously remove a brand product when adding a biosimilar, for example, sponsors will ultimately be paying more. “It's really an unintended consequence. It really comes down to our ability to use utilization management and how that utilization management drives outcomes and creates sustainable trend.”