Federal PBM Reforms: Transparency and Stakeholder Engagement

The Centers for Medicare & Medicaid Services (CMS) is aggressively pursuing federal reform efforts aimed at pharmacy benefit managers (PBMs) by soliciting stakeholder feedback on the new Medicare Part D provisions. These reforms introduce "delinking" requirements and revise PBM data reporting obligations, set to take effect in 2028. This initiative forms part of a broader movement to overhaul PBM compensation frameworks, targeting the reduction of incentives tied to escalating drug prices by adopting a service-based approach.

CMS seeks insights on several pivotal regulatory elements that could reshape contract structures, impact affiliated entities, and refine evaluation methods for revenue streams. A significant focus is on the role of PBM affiliates, including third-party administrators, potentially leading to expanded reporting duties amidst heightened scrutiny of vertically integrated healthcare models. By 2028, PBMs must submit annual reports detailing drug utilization, pricing, pharmacy reimbursement, and other financial metrics, aiming to bolster transparency across the Medicare Part D landscape.

Independent pharmacies have long pushed for greater transparency in PBM reimbursement and fee structures. The upcoming reporting mandates are expected to further clarify these financial interactions, especially within integrated organizations. Stakeholders are encouraged to contribute during the rule development phase, a critical opportunity to shape the regulatory landscape. Organizations that engage proactively will be better positioned for the forthcoming federal PBM reforms.

Buchanan Ingersoll & Rooney is vigilantly tracking these federal and state PBM reform initiatives, focusing on issues related to transparency, reimbursement, and network dynamics. Entities interested in evaluating the impact of these changes or devising a strategic response should connect with Lucas Morgan, Esq., or Dae Lee, Esq.