PBM Reform Act 2026: What Pharmacists Need to Know | Medicare & Medicaid Changes
- Key reforms to pharmacy benefit managers (PBMs) have been codified as part of HR 7148, the Consolidated Appropriations Act of 2026, which was signed into law by President...
- “Buddy” Carter (R–GA), sponsor of the original PBM Reform Act of 2025, a series of key initiatives from that bill were included in the Consolidated Appropriations Act.
- The legislation mandates that PBMs provide detailed, semi-annual reporting to employer plans regarding net drug spending, rebates, and “spread pricing” arrangements.
Key reforms to pharmacy benefit managers (PBMs) have been codified as part of HR 7148, the Consolidated Appropriations Act of 2026, which was signed into law by President Donald Trump on . The bill incorporates key provisions from HR 4317, the PBM Reform Act of 2025, aiming to increase transparency, improve pharmacy access, and reform PBM business practices within Medicare and Medicaid.
What Reforms Are in the Legislation?
According to Representative Earl L. “Buddy” Carter (R–GA), sponsor of the original PBM Reform Act of 2025, a series of key initiatives from that bill were included in the Consolidated Appropriations Act.
Health Plan Transparency
The legislation mandates that PBMs provide detailed, semi-annual reporting to employer plans regarding net drug spending, rebates, and “spread pricing” arrangements. These reports must also explain benefit designs that incentivize patients to use PBM-affiliated pharmacies. The law ensures that summary documents are made available to PBM participants and beneficiaries, providing them with information about a plan’s drug spending and coverage.
PBM Accountability for Medicare Part D Beneficiaries
Beginning in , PBMs and their affiliates will be prohibited from receiving remuneration for Part D services beyond “bona fide service fees.” These fees must be a flat dollar amount, tied to services genuinely performed, and consistent with fair market value.
PBMs will also be required to report more thoroughly—on an annual basis—to Part D plan sponsors. These reports must include drug-specific and aggregate data on factors like manufacturer-derived revenue, total gross spending, and average pharmacy reimbursement amounts, broken down by dispensing channel. Prescription drug plan (PDP) sponsors will also have the right to conduct annual audits of their PBMs to ensure compliance with agreement terms and information accuracy.
“Any Willing Pharmacy” Protections
The PBM reforms mandate that, starting in , Part D sponsors must allow any pharmacy meeting standard contract terms to participate in their network, a policy known as any willing pharmacy. The Secretary of the Department of Health and Human Services (HHS) is directed to establish standards for “reasonable and relevant” contract terms by .
A new category of “essential retail pharmacies” has been established, including those in rural, underserved, or urban areas with limited access. The HHS secretary must publish a list of these pharmacies and report on their network participation and reimbursement trends.
Pharmacies will now have a formal process to report contract violations with PBMs. PDP sponsors are prohibited from retaliating against or coercing pharmacies that submit allegations, with penalties for non-compliance.
What Do These Reforms Mean for Pharmacists?
These reforms are intended to shift the balance of power from PBMs towards individual pharmacies, allowing for increased reimbursement transparency. According to the American Pharmacists Association (APhA), which supported the legislation, pharmacists will have stronger reimbursement options through Medicare and be able to more sustainably dispense medications.
Michael D. Hogue, PharmD, FAPhA, FNAP, FFIP, executive vice president and CEO of APhA, stated that the reforms signal progress towards a modernized payment system that recognizes the essential role of pharmacists in dispensing. They could allow for heightened delivery of pharmacist-based clinical and preventive services, potentially reducing Medicare costs and improving patient outcomes.
However, Hogue and APhA note that these reforms should be coupled with legislation that recognizes and covers pharmacist-provided care services through Medicare. Specifically, HR 3164, the Ensuring Community Access to Pharmacist Services Act, was not included in the Consolidated Appropriations Act of 2026; passage of that bill would ensure consistent, covered access to essential services provided by pharmacists, such as testing, treatment, and vaccinations.
“While these reforms begin to address one of the most significant challenges pharmacists face under Medicare, they represent one part of the broader effort needed to strengthen pharmacy access and fully support patient care,” Hogue said. “To truly improve health care delivery, Congress and Medicare must also now recognize and pay for the patient care services that pharmacists provide every day.”
The impact of this new legislation on patients remains to be seen. Pharmacists should stay informed about changes to PBM practices and adjust their workflows accordingly to prevent disruption.