Major PBM Reform in Play? Shell Games Require Action

January and February have brought significant activity on the pharmacy benefit reform front at the federal level—a long time in coming, but it is not yet time to celebrate. Separate federal and congressional focus on pharmacy benefits management (PBM) oversight initiatives have the potential to create significant changes as they compound on future and past efforts to better manage health benefit coverage. But that potential cannot be realized until we expand this current activity to include the upstream and downstream impact of not just PBMs but also their affiliated entities. Too many billions of dollars are being shifted from one pot to another in an ever-present shell game that will cripple tightly worded oversight language.

PBM Reform Law for Medicare Part D Patients

On February 3, President Trump signed into law the 2026 Consolidated Appropriations Act¹ (CAA), which extended funding to several federal departments and agencies and included key elements of PBM reform intended to increase transparency, preserve patient access to care, and lower healthcare costs by reforming the PBM middleman model for Medicare Part D plans.

The PBM-focused policies of the 2026 CAA include:

• Prohibition of PBM remuneration for covered Part D drugs
• Clarification of drug and drug pricing contracts in a transparent and consistent manner
• Annual requirements for reporting and auditing for Part D plan sponsors
• Pricing transparency, data, and reporting required by PBMs for group health plans and issuers
• Requiring Part D plans to allow any qualified willing pharmacy participation by 2029, with additional contracting terms and oversight of pharmacy and plan relationships
• A new category of “essential retail pharmacies” in underserved areas with reporting on reimbursement, participation, and cost-sharing impacts
• Establishing a formal process for pharmacies to report contract-related violations and authorizes enforcement actions and penalties against noncompliant plans or PBMs²

Reactions to the PBM reforms embedded in the CAA have been celebratory but cautious. Various congressional legislative PBM reforms have been proposed for years without successful progression into law. This reform affects Medicare Part D plans, but not other PBM activity in ACA Marketplace, Medicare Advantage, Medicaid managed care, 340-B, commercial, or self-insured employer plans. This milestone legislation may move the conversation forward, but it will not immediately change PBM impact on almost two-thirds of American drug coverage.³

Federal PBM 2026 Lawsuit

The Federal Trade Commission (FTC) and Express Scripts (owned by Cigna) announced a landmark settlement on February 4, 2026, that allowed Express Scripts to separate from an FTC lawsuit against PBMs for inflating the cost of insulin in exchange for major changes in drug benefit design for one of the largest PBMs in the United States. The ongoing FTC lawsuit that began in September 2024 continues against the other two largest PBMs—UnitedHealth’s Optum RX and CVS’ Caremark.

Express Scripts agreed to stop preferring drugs with high list prices on standard formularies over cheaper equivalents, to increase transparency on drug pricing and spending as well as on kickbacks from brokers (intermediaries between PBMs and customer employers), and to delink its compensation from negotiated savings with drug manufacturers. Another aspect of the settlement should help many patients (members of Express Script employer clients and Cigna’s fully insured health plans) whose out-of-pocket costs will be based on net drug prices after savings Express Script negotiates with drug manufacturers. Express Scripts also agreed to pay community pharmacies based on the actual cost of the drugs plus a fee for dispensing.

One surprising, but key, aspect of the settlement was the movement of Ascent (Express Script’s group purchasing organization [GPO]) from Switzerland back to the United States. Most PBM GPOs are located internationally, which hampers federal oversight of PBM pricing and sourcing.⁴

Department of Labor Proposed PBM Rule Seeks Comments

On January 29, 2026, the US Department of Labor (DOL) proposed landmark regulation setting forth transparency requirements that affect not only PBMs but also the self-insured group plans that contract with them. By requiring PBM transparency into drug costs and fee disclosures, the DOL is advancing movement toward employer fiduciary responsibility fulfillment requirements under the Employee Retirement Income Security Act. The notice of proposed rulemaking—Improving Transparency Into Pharmacy Benefit Manager Fee Disclosure—was published in the Federal Register on January 30, 2026, and comments are due by March 31, 2026. www.federalregister.gov/documents/2026/01/30/2026-01907/improving-transparency-into-pharmacy-benefit-manager-fee-disclosure

The DOL PBM proposed rule will for the first time require PBMs to disclose:

• Rebates and other payments from drug manufacturers
• Compensation received when the price paid by the plan for a prescription drug exceeds the amount reimbursed to the pharmacy
• Payments recouped from pharmacies in connection with prescription drugs dispensed to the plan
• Allow plan fiduciaries to audit the accuracy of PBM disclosures and provide relief for plan fiduciaries if their PBM fails to meet its obligation

PBM GPOs—Exposure of a PBM Goldmine

PBMs and their affiliates (upstream: health plans; downstream: GPOs, pharmacies, etc) are heavily leveraged in horizontal and vertical integration. Transparency demands have historically not presented much of a threat to the PBM and health plan business models because of the diversity of their revenue streams. Costs to patients and employers continue to rise, while billions of dollars of nontransparent profit are reaped by each component of an integrated health plan/PBM/GPO, specialty pharmacy, and dozens of other affiliated entities. PBM GPOs have recently become a critical element of the revenue stream, collecting rebates and fees from drug manufacturers on top of the PBMs own administrative service fees to their employer clients. Most “transparent rebate pass-through” information released by PBMs does not reflect these diverted revenues, including funds collected through PBM GPOs, usually foreign entities.⁵

Hunterbrook Media focused a year-long investigative report on some PBM-affiliated GPO structures, revealing lightly staffed foreign entities collecting substantial manufacturer payments from within the drug pricing ecosystem affecting US-based patients and employer PBM clients. The report explores CVS, UnitedHealth, and CIGNA PBM GPO subsidiaries (Zinc, Emisar, and Ascent, respectively) and their tens of billions in revenue. Key healthcare strategy leaders are calling for deeper investigation into the PBM GPO financial streams and the potential connection to exploding healthcare costs. During the congressional hearing on January 26, 2026, legislators grilled the insurance plan CEOs on the role and revenues of their subsidiary PBM GPOs.⁶

What Can Practices Do?

Healthcare has become big business for far too many entities that are not a critical part of the patient/physician dynamic. Healthcare is now a defined revenue stream for organizations more focused on stockholder returns and billions of dollars of profits, and patients and employers are being asked to pay the price, both financially and medically. Physicians and practices must speak up as advocates for their patients in addition to providing medical care.

Congress and the federal government have finally taken several steps forward in the last few weeks to curb some of the excess and abuse that have been allowed to proliferate unfettered for decades. There is growing realization that large for-profit organizations have become very adept at diversifying, integrating, and insuring into multiple affiliates that each have their opportunity to siphon profits off the backs of patients, employers, and the treating providers, as well as the supply of essential drugs needed for innovation and treatment. We need to raise our voices in support of current and planned regulation and oversight, but also to warn about the proliferation of middlemen siphoning revenues with no legitimate medical purpose. Regulation must allow for exposure of hidden goldmines and affiliated entities that reap billions of dollars in profit that contribute to healthcare costs without added value for the patient and for society.

Please comment before March 31, 2026 on the DOL- proposed PBM rule. This document is available online at https://federalregister.gov/d/2026-01907 and at https://govinfo.gov.

You may submit comments, identified by RIN 1210-AB37, by one of the following methods:

• Federal eRulemaking Portal: www.regulations.gov. Follow the instructions for submitting comments
• Mail or personal delivery: Office of Regulations and Interpretations, Employee Benefits
  Security Administration, Room N-5655,
  US Department of Labor, 200 Constitution
  Avenue NW, Washington, DC 20210
  Instructions: All submissions received must include the agency name and Regulation Identifier Number (RIN) for this rulemaking.

Warning: Do not include any personal identifiable or confidential business information that you do not want publicly disclosed. Comments are public records posted on the internet as received and can be retrieved by most internet search engines.

As of the morning of February 9, 2026, there were just 4 comments filed. This is the time to speak up. We need patients, physicians, practice staff, employers, patient advocates—all those affected by these shell games with our healthcare dollars, to support and strengthen the DOL proposed rule.

Now is the time to call not just for transparency, data protection, and reporting, but to go deeper.

• Call out the complexity of the horizontal and vertical integration, the creation of revenue siphoning entities that add administrative burden and pass-through transactions not directly done by the PBM, and the ability of PBMs to shield monies from simplistic legislation
• Call for open markets, elimination of rebate models, masking of revenue transfers as administrative services rather than “reportable fees”

Many states are also actively involved with PBM legislation. Do not lose the opportunity to speak up in your own state regarding PBM oversight and control. Your state oncology society is a good resource for involvement.

Please share your thoughts and experiences with me at This email address is being protected from spambots. You need JavaScript enabled to view it.. I would be interested in hearing what you have found, or what more you want to know. I can provide additional resources on this topic if you wish.

References

1. H.R. 7148 – Consolidated Appropriations Act, 2026. Accessed February 9, 2026. www.congress.gov/bill/119th-congress/house-bill/7148
2. Carter B. A new era for patients: Carter celebrates President Trump signing PBM reforms into law. United States Representative Buddy Carter Press Release. February 3, 2026. Accessed February 8, 2026. https://buddycarter.house.gov/news/documentsingle.aspx?DocumentID=16308
3. Potter W. PBM Reform Comes to Washington But It’s Only the Tip of the Iceberg. Health Care un-covered. February 4, 2026. Accessed February 7, 2026. https://healthcareuncovered.substack.com/p/pbm-reform-comes-to-washington-but?utm_source=post-email-title&publication_id=255152&post_id=186823710&utm_campaign=email-post-title&isFreemail=true&r=1r8ai8&triedRedirect=true&utm_medium=email
4. Parduhn RP. Express Scripts reaches ‘landmark’ settlement with FTC in insulin suit. Healthcare Dive. February 4, 2026. Accessed February 7, 2026. www.healthcaredive.com/news/express-scripts-ftc-reach-settlement-insulin-lawsuit/811369/?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202026-02-04%20Breaking%20News:%20Healthcare%20%5Bissue:81431%5D&utm_term=Healthcare%20Dive
5. Buchanan Insights. When Pass-Through Isn’t Pass-Through: PBM GPOs and the Reengineering of Rebates. January 8, 2026. Accessed February 4, 2026. www.bipc.com/when-pass-through-isn%E2%80%99t-pass-through-pbm-gpos-and-the-reengineering-of-rebates
6. Wadsten L, Ford A. Congress Grills Health Insurance CEOs With Hunterbrook Exposé. Hunterbrook Media. January 25, 2026. https://hntrbrk.com/pbm-gpo-congress/