PBM Legislation Can Mitigate Negative Impacts on Rural Patients, Pharmacies

Pharmacy benefit manager (PBM) legislation focused on a variety of categories has the potential to significantly impact pharmacy operations and patient outcomes in rural areas, according to a study published in Exploratory Research in Clinical and Social Pharmacy.¹ However, more research is needed to understand the financial and clinical impact of these legislative categories.

“Pharmacy Benefit Managers (PBMs) are third-party organizations acting as intermediaries between insurance companies, pharmacies, and drug manufacturers,” wrote authors of the study. “Currently, PBMs are highly integrated into the health care system through their various roles, including developing drug formularies and negotiating drug prices and rebates with manufacturers. They also perform administrative functions on behalf of insurance companies and handle pharmacy reimbursements.”

Most pharmacy industry experts are aware of PBM practices, and those that have been impacted by them the most in day-to-day pharmacy practice have been calling for PBM reform from the federal government. However, from events like the scaling down of 2024’s year-end spending bill,² PBM reform on the federal level has yet to come to fruition.

In rural areas, patients and pharmacies alike face financial instability and depleting access to health care. | image credit: Iren Moroz / stock.adobe.com

This has led many states to take action instead.

Recently, states like Arkansas and Iowa have enacted legislation intended to take control from PBMs,^3,4 joining the rest of the 50 states who are currently considering signing bills that would impact PBMs or prescription drug benefits.⁵

“The reimbursement process consists of pharmacies stocking and dispensing medications while PBMs are responsible for managing copays and determining the amount to reimburse a pharmacy through negotiated contracts,” wrote authors of the current study.¹ “However, PBMs have proprietary practices and methodologies that make it unclear how values for reimbursement are determined.”

READ MORE: The Ongoing Challenges Causing Need for Reform in Retail Pharmacy

In rural areas specifically, patients and pharmacies face financial instability and depleting access to health care. If PBMs reimburse below dispensing price at all pharmacies across the country, those in rural locations will be hit the hardest because of their ongoing barriers to valued care.

With these pharmacy challenges and trends in store closures, advocates and legislators have kept a close eye on these issues and drafted legislation to correct the impact of PBMs. Researchers reviewed the collection of PBM legislation and determined its benefits toward patients and pharmacies in rural areas.

“There is currently a gap in pharmacy literature concerning the impact PBM legislation has on rural pharmacy practice and communities,” they continued.¹ “This study aims to review the legislation compiled by the National Community Pharmacists Association (NCPA) to determine how this oversight benefits pharmacies and patients in rural communities.”

Researchers explored NCPA-supported bills from November 30, 2018, to December 7, 2021. They were classified as enacted, in debate, or failed, and they were only included if they were designed to benefit either patients or pharmacies.

A total of 57 bills were identified and placed into 1 of 6 categories: PBM operations, drug pricing, transparency, reimbursements, cost sharing, and prior authorization. Of all 57 bills included, 22 of them (38.6%) were created to impact patients and pharmacies alike.

“Rural patients and community pharmacies face unique challenges and disparities, often intensified by PBM policies and procedures,” wrote the authors.¹ “Addressing PBM reform through the lens of its benefits for rural pharmacies and patients provides a valuable perspective on the legislation's potential impact.”

Looking at pharmacy sustainability through rural locations has the potential for placing a much wider scope on the issue of PBMs in the prescription drug market. Because pharmacy closures have led to pharmacy deserts, specifically prominent in low-population areas, rural locations serve as preceptors for how PBM reform actually influences improvement in the respective location.

“Achieving sustainability and efficacy in rural pharmacies demands a comprehensive approach, encompassing policy changes, financial support mechanisms, and an understanding of the specific health care needs of rural populations,” they concluded.¹ “Continued advocacy for research and policy reform is crucial to increase support for rural pharmacies. This endeavor is essential to mitigate health care disparities in rural areas, enhance health care access and quality, and ensure equitable access to health care for all individuals, regardless of their location.”

READ MORE: How State-Level PBM Reform Can Lead to Federal Legislation

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References

1. Melton TC, Ryan M, Stallings AM, et al. Through the lens of rural patients and pharmacies: a content analysis of state level pharmacy benefit manager regulations and policies. Explor Res Clin Soc Pharm. 2025;18:100595. https://doi.org/10.1016/j.rcsop.2025.100595

2. Weixel N. House GOP drops PBM reforms in scaled-down spending bill. The Hill. December 19, 2024. Accessed July 10, 2025. https://thehill.com/policy/healthcare/5049676-house-republicans-drop-pbm-reform/

3. Nowosielski B. As a result of PBM reform, CVS will close over 20 pharmacies in Arkansas. Drug Topics. April 22, 2025. Accessed July 10, 2025. https://www.drugtopics.com/view/as-a-result-of-pbm-reform-cvs-will-close-over-20-pharmacies-in-arkansas

4. Nowosielski B. Iowa governor signs bill limiting PBM practices. Drug Topics. June 12, 2025. Accessed July 10, 2025. https://www.drugtopics.com/view/iowa-governor-signs-bill-limiting-pbm-practices

5. Myshko D. States become more aggressive with PBM reform. Managed Healthcare Executive. May 30, 2025. Accessed July 10, 2025. https://www.managedhealthcareexecutive.com/view/states-become-more-aggressive-with-pbm-reform