The PBM Reform Act of 2025 would change rules about pharmacy networks, pharmacy benefit managers (PBMs), and drug payment reporting. Key provisions in the bill text include:
Medicare Part D network access: PDP sponsors (plans) must allow any willing pharmacy that meets the plan's contract terms to join network pharmacies. The Secretary of Health and Human Services must set standards for what contract terms are "reasonable and relevant" by April 2028. A request for information is required by April 1, 2027.
Essential retail pharmacies: The Secretary must publish a public list and recurring reports (every 2 years until 2034 and periodically thereafter) about "essential retail pharmacies" that serve underserved, rural, suburban, or urban areas with limited nearby pharmacies. Plans and PBMs must submit data to help identify these pharmacies and report incentive payments and fees.
Enforcement and pharmacy allegations: CMS must create a process (by January 1, 2028) for pharmacies to submit allegations that a PDP sponsor violated the standards for contract terms. The process includes document access, a template, protections against retaliation, investigations, and possible civil monetary penalties or sanctions.
PBM accountability and transparency for Medicare plans: New contract rules would require PDP sponsors to have written agreements with PBMs that, among other things, require PBMs to disgorge improper remuneration, provide detailed annual reports to sponsors and the Secretary (drug lists, utilization, rebates, amounts retained by PBMs and affiliates, affiliate pharmacy data, manufacturer agreements, and more), allow sponsor-selected audits, and permit PDP sponsors to hold PBMs financially responsible for penalties tied to delegated PBM responsibilities.
Studies and reports: The Comptroller General (GAO) must study price-related compensation across the supply chain and report to Congress. MedPAC must prepare reports based on available data about PBM agreements and effects on enrollees and pharmacies.
Group health plan and employer plan oversight: New requirements (added to the Public Health Service Act, ERISA, and the Internal Revenue Code) require PBMs that serve group health plans or issuers to provide semiannual (or quarterly on request) machine-readable reports to plans with detailed drug, payment, rebate, and dispensing-channel information. There are penalties for failing to report or for knowingly providing false information.
Medicaid pharmacy pricing and surveys: The bill requires CMS to run monthly surveys to determine national average drug acquisition cost benchmarks (including retail and certain non-retail pharmacies). States must require pharmacies to respond to these surveys. The HHS Inspector General will study survey data and report to Congress. The bill also requires transparent pass-through pricing in State contracts with PBMs or managed care entities and limits use of spread pricing for Federal matching payments.
Funding and implementation details: The bill text includes multiple appropriations and sets deadlines for rulemaking, guidance, and implementation for the new requirements.
If you are a Medicare Part D enrollee: Plans would be required to permit more pharmacies to join networks if the pharmacies meet contract standards. The bill would also require more information from PBMs and plans about drugs, prices, and rebates that could be used for oversight and reporting.
If you run or work at a pharmacy: Plans and PBMs must follow new contract standards. Pharmacies designated as "essential retail pharmacies" would be identified and tracked. Pharmacies could submit allegations to CMS if they believe plan contracts violate the new standards, and the bill includes anti-retaliation protections for doing so.
If you work for or run a PBM or plan sponsor: The bill would require written agreements, detailed annual and semiannual reports, audit access, and contractual liability for certain violations. Group plans would get detailed reporting from PBMs every 6 months (or quarterly on request).
If you are a state official: State Medicaid contracts and managed care contracts would need to follow the pass-through pricing model and make survey participation mandatory for pharmacies. States would also receive more CMS data about pricing categories.
The bill text includes explicit appropriations and funding provisions:
No publicly available information on the bill's total net budgetary effect beyond the specific appropriations listed in the bill text.
The bill text states its purpose "to assure pharmacy access and choice for Medicare beneficiaries, and for other purposes." The bill's provisions show proponents seek to:
These aims and the specific reporting, audit, and enforcement provisions are stated in the bill text.
No publicly available information.