How States and Federal Government Are Reforming PBM Practices for Pharmacy Viability | APhA 2026

Although federal legislators and government entities are well aware of what pharmacy benefit managers (PBMs) are and why reforming them is desirable for respective parties, state-level reform actions are a much more viable path forward to improving pharmacy sustainability.

“In my pharmacy, my contracts with various PBMs entail a range of different reimbursement amounts that include, in a lot of cases, situations where every brand-name drug dispensed would be paid 10% below my cost to acquire the drug,” Benjamin Jolley, PharmD, pharmacist at Jolley’s Compounding Pharmacy and co-founder of Apex Pharmacy Consulting, said in a presentation hosted at the American Pharmacists Association 2026 Annual Meeting and Exposition.¹ “This means that to dispense medication to my patients would be a significant financial burden and may cause the pharmacy to not be profitable and, therefore, eventually go out of business.”

According to Jolley, the “PBM Hunger Games” are reaching a critical turning point as community pharmacists across the nation fight for a reimbursement landscape where the odds might finally be in their favor.

READ MORE: Pharmacy Law Lowdown: Actions Against PBM Practices

Years of opaque pricing, “shady tactics,” and underwater reimbursements have sparked a massive wave of state and federal reform aimed at ensuring pharmacy viability.^2-4

The pharmacist’s financial survival struggle has moved from the pharmacy counter to the halls of Congress and state legislatures, where policymakers are finally beginning to understand the role of these middlemen.¹

Federal Reform Efforts

At the federal level, the 2026 Consolidated Appropriations Act (CAA) represents a significant shift, enacting transparency and reporting requirements that will begin to reshape the landscape for group health plans. These reforms, slated for full implementation by 2029, include drug-level reporting for large employers and a mandate for PBMs to pass through 100% of rebates to employer health plans.²

Furthermore, the Department of Labor has proposed rules to increase visibility into PBM compensation, and the Federal Trade Commission (FTC) has secured a landmark settlement with Express Scripts to overhaul its business model, particularly regarding insulin pricing. According to STAT News, these initiatives aim to realign PBM incentives with patients and payers by making these middlemen legally accountable as fiduciaries.^2,4,5

A major focal point for reform is the intense vertical integration of the industry, where the top 3 PBMs—OptumRx, Express Scripts, and CVS Caremark—now manage 79% of all prescription drug claims. This concentration of power has led to the introduction of the “Breakup Big Medicine Act,” which seeks to prohibit PBMs and insurers from owning pharmacies, wholesalers, or physician clinics.^1,5

State-Level PBM Reform

In states like Arkansas and Tennessee, lawmakers are battling to prevent “ghost networks” and patient steering—practices where patients are funneled toward PBM-owned specialty or mail-order pharmacies. The steerage issue, particularly, remains a primary concern for pharmacists, who often see claims rejected with instructions that patients must use PBM-affiliated services.

Although federal changes offer long-term hope, states have become the primary proving ground for immediate relief through the implementation of price floors. States including Colorado, Iowa, and Louisiana have enacted laws requiring PBMs to pay pharmacies at least the acquisition cost of each drug plus a professional dispensing fee.^1,5

These state-level victories are crucial because many pharmacists find the current maximum allowable cost (MAC) regulations to be ineffective, providing little protection against predatory pricing. Additionally, several states are moving toward single-PBM or fee-for-service models in Medicaid to prevent spread pricing—a practice where PBMs overcharge the state through the Centers for Medicare and Medicaid Services, while underpaying the dispensing pharmacy.

However, the PBM industry, represented by the Pharmaceutical Care Management Association (PCMA), argues that these mandates are duplicative and will ultimately hurt their ability to negotiate discounts. PCMA President David Marin contends that current reforms should be given time to ripen rather than being overlaid with further regulation.³

This debate occurs within a broader health care environment marked by leadership transitions at the FDA under Commissioner Marty Makary, MD, MPH, and shifting public health capacities at the CDC, which recently suspended testing for rabies and pox viruses. The regulatory pressure also coincides with administrative flux, including the Senate’s stalled confirmation of Casey Means, MD, as surgeon general.

Despite the industry's resistance, the momentum toward transparency suggests that for pharmacists, the era of the middleman operating in the shadows may finally be drawing to a close.^4,5

“Unlike 5 years ago, Congress, the FTC, and the Department of Justice are aware of and generally understand what PBMs are and why reform is necessary,” concluded Jolley during the presentation.¹ “While Congress is at a historical low in terms of bills passed, state legislatures have become the real proving ground for changing policy and reimbursement.”

READ MORE: APhA Annual Meeting and Exposition

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REFERENCES

1. Jolley B. PBM Hunger Games update: May reimbursement be ever in your favor. Presented at: American Pharmacists Association 2026 Annual Meeting and Exposition; March 27-30, 2024; Los Angeles, CA.

2. Arville AJ, Feiertag T, Worthen CB, et al. 2026 pharmacy benefit manager reform: what employers need to know. Epstein Becker & Green, P.C. February 24, 2026. Accessed April 2, 2026. https://www.ebglaw.com/insights/publications/2026-pharmacy-benefit-manager-reform-what-employers-need-to-know

3. Gardner S, Hooper K. Drug-pricing middlemen push back on reforms. Politico. April 2, 2026. Accessed April 2, 2026. https://www.politico.com/newsletters/politico-pulse/2026/04/02/drug-pricing-middlemen-push-back-on-reforms-00854536

4. Sood N. Washington is on the verge of true PBM reform. STAT News. March 30, 2026. Accessed April 2, 2026. https://www.statnews.com/2026/03/30/fair-act-pbm-reform-fiduciary-duty-to-patients/

5. Freed M, Cubanski J, Williams E, et al. What to know about pharmacy benefit managers (PBMs) and federal efforts at regulation. KFF. February 9, 2026. Accessed April 2, 2026. https://www.kff.org/other-health/what-to-know-about-pharmacy-benefit-managers-pbms-and-federal-efforts-at-regulation/