FAQ: How the 2026 Midterms Could Reshape Pharmacy Policy

With the 2026 midterm elections just weeks away, pharmacists have more on the line than usual. PBM reform has drawn rare bipartisan support, the 340B program is headed toward a possible Supreme Court showdown, and manufacturers are increasingly experimenting with selling directly to employers.

Each of these could reshape how pharmacies are reimbursed and who controls patient access to medications, among several other potential and yet uncertain outcomes stemming from the upcoming election.

“Pharmacists are at the center of several health policy debates heading into the 2026 midterms,” Adino “A.J.” Barbarito, Esq, senior associate in Frier Levitt’s Life Sciences Litigation practice group, told Drug Topics®. “Congress has already enacted federal reforms, and additional measures are moving forward.”

In part 1 of our FAQ series detailing key insights for pharmacists prior to the 2026 midterm elections, Drug Topics was joined by Barbarito to discuss some of the high-level health policies that will be fresh in voters’ minds heading into this year’s election. Read through his perspective on the legal side of pharmacy practice in order to stay ahead and be prepared for any potentially abrupt legislative changes coming in the future.

Stay tuned for more from our discussion with Barbarito, who delved even deeper into the specific policies regarding PBMs, Most Favored Nation drug pricing, subsidies from the Affordable Care Act, and how it all might impact pharmacies.

READ MORE: The Legislation Setting the Stage for Pharmacy’s Next Leap

What are some of the most discussed health policy issues heading into the 2026 midterms that directly impact pharmacists?

Pharmacists are at the center of several health policy debates heading into the 2026 midterms. Pharmacy benefit manager (PBM) reform and fair pharmacy reimbursement are major bipartisan issues. Congress has already enacted federal reforms, and additional measures are moving forward.

H.R. 3164, the Ensuring Community Access to Pharmacist Services Act, would provide Medicare Part B coverage for pharmacist testing and treatment of flu, respiratory syncytial virus (RSV), strep throat, and COVID-19. A House Energy and Commerce subcommittee held a hearing on this issue on September 15, 2026.

Other proposals address vertical integration between PBMs and pharmacies. The Patients Before Monopolies Act was reintroduced in May 2026 with bipartisan House and Senate sponsors and would require companies that own a PBM or insurer to divest their pharmacies. The Pharmacists Fight Back Act would use National Average Drug Acquisition Cost (NADAC) as a more transparent reimbursement benchmark. State action in at least a dozen states reinforces that federal momentum.

The 340B Drug Pricing Program is another major issue. Manufacturers are tightening restrictions on covered entities’ use of outside pharmacies to dispense 340B drugs, while more than 20 states have enacted laws barring those restrictions. Manufacturers have challenged many of these laws on preemption grounds. Most federal courts of appeals, including the 5th and 8th Circuits, have upheld these laws, but in March 2026, the 4th Circuit held that West Virginia’s law is likely preempted, creating a circuit split that may require Supreme Court review.

Direct-to-employer (DTE) arrangements are also entering the discussion. Manufacturer-run programs associated with Eli Lilly and Novo Nordisk, particularly for glucagon-like peptide-1 (GLP-1) medicines, can offer employers fixed, transparent pricing outside traditional PBM rebate structures. Three developments are driving this trend. First, the Consolidated Appropriations Act of 2026 (CAA 2026) enacted federal PBM reforms that take effect for plan years beginning on or after January 1, 2029. Those reforms require PBMs serving employer plans to pass 100% of manufacturer rebates and fees through to the plan and give plans new disclosure and audit rights. The ban on spread pricing and the delinking of PBM compensation from drug prices apply to Medicare Part D beginning in 2028.

Second, the Department of Labor (DOL) has proposed a rule that would apply to self-funded employer plans and require PBMs to disclose their compensation; it is not yet final. Third, a wave of lawsuits under the Employee Retirement Income Security Act (ERISA) has accused employers of failing to manage their pharmacy benefits prudently. One example is Lewandowski v. Johnson & Johnson. The case was dismissed for lack of standing and is now on appeal, but it has still prompted employers to scrutinize PBM contracts.

Together, these pressures are prompting employers to take a closer look at alternatives to traditional PBM arrangements. From a pharmacist’s perspective, Lilly’s Employer Connect platform (launched March 2026) offers Zepbound at a set $449 price through independent program administrators and a designated pharmacy network; the manufacturer, rather than the PBM, sets the terms of access. Novo Nordisk has announced a similar program. Replacing a PBM may therefore create a new gatekeeper without restoring volume to independent pharmacies, and any-willing-provider laws are generally written around insurers and PBMs rather than manufacturers.

What are some new challenges or opportunities that are expected to arise following the results of this year’s midterms, whether it’s a Republican- or Democrat-led Congress going forward?

Regardless of which party controls Congress after the midterms, pharmacists should prepare for continued pressure on drug pricing, PBM practices, and health care affordability. A Democratic-led Congress would likely prioritize restoring ACA subsidies, expanding Medicare drug price negotiation, and intensifying oversight of health care consolidation and vertical integration.

However, given the reality of a Republican-controlled executive branch, there would be no guarantee that those bills would become law. Democrats would be unlikely to have enough votes to override a presidential veto. As such, legislative outcomes could depend on bipartisan negotiations, presidential support, or executive and regulatory action. A Republican-led Congress would likely focus on deregulation, consumer-choice models such as health savings accounts (HSAs), codifying the Most Favored Nation (MFN) framework, and continued PBM and 340B reforms. Coverage disruptions from Medicaid changes and subsidy expirations could nevertheless place financial strain on pharmacies, particularly in rural areas.

Bipartisan priorities that could advance under either scenario include PBM transparency, site-neutral payment reform, and the FDA user-fee reauthorization package in September 2027. These user-fee laws allow the FDA to collect fees from drug and device manufacturers to help fund its review of new products. Congress must renew them every 5 years. Because the current authority expires on September 30, 2027, the reauthorization is considered must-pass legislation and often serves as a vehicle for other health policy changes. Site-neutral payment reform generally means paying the same Medicare rate for a service regardless of whether it is delivered in a hospital outpatient department, in a physician office, or another lower-cost setting. Federal health care policy is increasingly shaped through executive action and rulemaking, not only through legislation, making the policy landscape more fluid and less predictable.

READ MORE: Law and Regulations Resource Center