Part 2: What to Watch Next A 2026 PBM Oversight and Advocacy Roadmap

The momentum surrounding Pharmacy Benefit Manager (PBM) oversight continues to grow. With bipartisan support, attention is intensifying on how PBM practices impact drug affordability, patient access, and the broader healthcare system. Federal agencies and state regulators along with Congress are all playing key roles in shaping the policy conversation that will define the future of PBM regulation. With ongoing investigations and hearings in Congress, and continued scrutiny from federal agencies like the Federal Trade Commission (FTC), the coming year is set to be pivotal for the healthcare and pharmacy industries.

Momentum Heading Into 2026

PBM oversight remains a hot-button issue, with ongoing investigations and hearings from both congressional committees and federal regulators. For example, the House Energy & Commerce Committee examined the prescription drug supply chain with a hearing titled Lowering Health Care Costs for All Americans in February 2026. Additionally, the House Ways & Means Committee hosted Hearing with Health Insurance CEOs in January 2026, and the House Budget Committee addressed the skyrocketing costs of healthcare in its Reverse the Curse session.

The heightened focus on drug affordability, patient access, and market transparency suggests that 2026 will be a year of increased regulatory action, with significant implications for patients, providers, and insurers alike.

Policy Areas to Watch in 2026

1. Spread Pricing Transparency

One of the central areas of concern in PBM regulation is spread pricing. This is the practice where PBMs charge health plans more for a drug than they reimburse pharmacies, pocketing the difference. Increasing transparency around this practice is critical to ensure that both patients and providers are not paying inflated prices for medications.

2. Rebate Reform and Pass-Through Requirements

Recent federal legislation requires a 100% pass-through of rebates to the plan sponsor, while state bills vary. Some states are pushing for rebates to be passed through to health plans, while others are aiming to pass rebates directly to patients at the point of sale. Given the direct impact on patient out-of-pocket costs, advocates believe that passing rebates directly to patients is the most effective way to lower prescription drug costs.

3. Prior Authorization Reform

One NORM member shared a direct experience where prior authorization issues affected a patient with severe rheumatoid arthritis. The patient had been stable on a biologic medication for over two years with no changes to her diagnosis or treatment plan. In January, a new prior authorization requirement was introduced. It took over three weeks to get approval, during which time she missed her infusion, experienced a flare-up, and required steroids and additional visits.

This is not an isolated case. It happens every day in our Rheumatology practices. Advocates are prioritizing the reform of prior authorization practices, aiming for faster approvals and less interference in the patient-provider relationship.

4. Reporting and Audit Requirements

New legislation and regulatory initiatives may require PBMs to report on their pricing practices, rebates, and other financial arrangements to allow regulators, health plans, and patients to better understand the true cost of medications. These efforts will help create a more accountable PBM landscape and provide better insights into how drug pricing is affecting the healthcare system.

5. State vs. Federal Action Interplay

The interplay between state and federal action will be critical in determining whether a unified framework can emerge or whether states will continue to have significant autonomy in regulating PBMs. Recently enacted “landmark” PBM provisions including banning spread pricing in Medicaid, delinking in Medicare Part D, and rebate pass through to plan sponsor will not go into effect until 2028.

Vertical Integration: Combating Conflicts of Interest

One issue that has received increased attention is the trend toward vertical integration in the pharmacy industry. PBM ownership of pharmacies is a growing concern, as it can create conflicts of interest that may undermine patient care and drive up costs. Arkansas was the first state to enact legislation banning PBM ownership of pharmacies. These efforts aim to prevent PBMs from benefiting financially by owning pharmacies and controlling the prescription drug supply chain, which could result in biased decisions that harm patients.

For instance, Aetna recently moved several buy-and-bill medications to CVS Specialty or switched formulary options, making the alternative financially unfeasible for providers under the buy-and-bill model. This shift disrupts established relationships between patients and providers and complicates the delivery of care.

Practical Implications for Practices

Healthcare providers, particularly those in specialty practices, should monitor the following developments:

• Policy Areas to Watch: Stay informed about the policy areas outlined above, especially those impacting reimbursement models, prior authorization processes, and transparency in pricing and rebates.
• Shifting Reimbursement Models: As new laws are enacted, reimbursement models may evolve, and practices may need to adjust their operations to accommodate changes in how PBMs are compensated.
• Compliance and Documentation: Practices should prepare for potential changes in reporting and audit requirements. Staying compliant will be essential as PBM regulations become more stringent.

Education, Communication, and Advocacy

Staying informed and engaged is key to ensuring that the regulatory environment aligns with the needs of patients and healthcare providers. Organizations including NORM, ATAP, CSRO, ACR, and NICA, are committed to monitoring the situation, submitting comments on relevant legislation, and keeping members updated on developments. NORM’s position focuses on improving patient access to affordable medications, supporting responsible oversight, and ensuring that policies reflect the best interests of the patient community.

Access the NORM Advocacy Toolkit to learn how to “Build the Foundation and Become a Resource” to policymakers using the following link: https://membership.normgroup.org/sites/default/files/content-files/8.5%20x%2011in%20NORM%20Advocacy%20Toolkit.pdf

More ways to get involved include:

• Participating in Capitol Hill Days
• Writing directly to lawmakers
  • NORM members can view the organization’s advocacy letters here: https://membership.normgroup.org/advocacy-letters
• Submitting testimony
• Joining coalition efforts

Comment Opportunities: Make Your Voice Heard

Several agencies are currently seeking public comments on proposed regulations, offering a chance for stakeholders to provide input:

• U.S. Department of Labor (ERISA): Improving transparency into PBM fee disclosure (April 15).
• Federal Trade Commission (FTC): Consent Order for Express Scripts (ATAP submitted comments).
• Centers for Medicare & Medicaid Services (CMS): FY27 MAPD Rule (NORM submitted comments).

Conclusion: A Dynamic and Ongoing Conversation

The conversation surrounding PBM oversight is dynamic and multifaceted, with momentum building from both federal and state levels. As the regulatory landscape continues to evolve, it is essential for healthcare providers, patients, and advocates to stay engaged, monitor key policy areas, and actively participate in advocacy efforts. Your voice is important. With a commitment to transparency, patient access, and responsible oversight, the future of PBM regulation will shape the accessibility and affordability of medications for years to come.

- NORM Advocacy & HHS