The Next Wave of PBM Reform: What It Means for Employers and Plan Sponsors
The Next Wave of PBM Reform
Across the country, prescription-drug reform is taking center stage again. Over the past few months, both federal agencies and state legislatures have been rolling out new proposals aimed at reshaping how pharmacy benefit managers (PBMs) operate.
At the same time, PBMs themselves are beginning to respond, proactively changing business practices in hopes of staying ahead of pending regulation. For benefits leaders, the result is a landscape in motion, with real implications for cost, compliance, and care access.
PBMs Move Before Regulators Do
In late September, several large PBMs proposed internal reforms to improve pricing transparency and network accountability. These proposals range from enhanced reporting of pharmacy reimbursements to optional “clean claim” models that strip away spread pricing and rebate layers.
The timing is no coincidence. With scrutiny from policymakers and the public at an all-time high, PBMs are trying to show that the industry can modernize without heavy-handed oversight. Whether these self-directed moves are enough remains to be seen, but the shift signals one clear trend: the traditional PBM model is evolving fast.
States Step in to Regulate Drug Costs
At the same time, state lawmakers are not waiting for Washington. Nearly two-thirds of states have passed or introduced legislation this year designed to tackle prescription-drug costs—and most of those laws include PBM-specific provisions.
Some states are introducing audit requirements and turnaround-time standards. Others are imposing fee caps, rebate reporting, or “fair reimbursement” rules for pharmacies. While these efforts share the goal of protecting patients and local pharmacies, the patchwork of regulations creates new complexity for national and multi-state employers.
For plan sponsors, that means your PBM contract (and your overall pharmacy strategy) must be nimble enough to navigate multiple jurisdictions and pricing frameworks at once.
What Employers Should Be Watching
Benefits leaders should keep an eye on three key areas in the months ahead:
- Network stability: Rapid changes in reimbursement rules can affect which pharmacies stay in network and at what cost.
- Transparency requirements: Employers should expect more detailed reporting obligations, both from PBMs and state regulators.
- Plan compliance: The more fragmented the state landscape becomes, the greater the need for centralized oversight of claims and payments.
Each of these factors influences your bottom line and your plan members’ experience at the pharmacy counter.
Sources:
- Stateline, “Dozens of states tackle high prescription drug costs,” October 30, 2025 — https://stateline.org/2025/10/30/dozens-of-states-tackle-high-prescription-drug-costs/
- MassMarketRetailers, “NACDS calls PBM plan ‘self-policing,’” September 25, 2025 — https://massmarketretailers.com/nacds-calls-pbm-plan-self-policing/
- Becker’s Hospital Review, “PBMs draft plan to change business practices: 4 things to know,” September 24, 2025 — https://www.beckershospitalreview.com/pharmacy/pbms-draft-plan-to-change-business-practices-4-things-to-know/
Reuters, “Pharma middlemen propose regulatory changes to avoid regulations,” September 24, 2025 — https://www.reuters.com/business/healthcare-pharmaceuticals/pharma-middlemen-propose-changes-avoid-regulations-trump-administration-2025-09-24/
About ProCare Rx
ProCare Rx is a privately held, independent pharmacy benefit manager (PBM) that has empowered healthcare and self-insured organizations since 1988. We provide fully integrated, in-house solutions—including claims adjudication, clinical program design, pharmacy network access, cost containment, and data analytics—all supported in the U.S. Our flexible, transparent model serves self-insured employers, third-party administrators (TPA), brokers, health plans, health systems, managed care organizations (MCO), unions, workers’ compensation programs, Medicare, Medicaid, hospices, and other PBMs. With a proprietary technology platform, commitment to ethical operations, and a focus on lowest net cost, ProCare Rx delivers long-term value, clinical performance, and trusted pharmacy benefit partnerships.
Media Contact:
Marc Cohen, VP, Marketing and Sales
marketing@ProCareRx.com
