PBM Reform Act of 2025
Summary
What This Bill Does
The bill mandates any willing pharmacy participation in Medicare Part D networks with reasonable and relevant contract terms, creates essential retail pharmacy protections for underserved areas, establishes allegation process, requires PBMs in Medicare Part D to limit remuneration to bona fide service fees, mandates full pass-through of manufacturer rebates, imposes extensive annual reporting on drug costs and PBM compensation including, and requires extends PBM transparency and oversight requirements to employer-sponsored group health plans across PHSA, ERISA, and the Internal Revenue Code. It relies on compliance mandates, reporting requirements, product standards, and appropriations. The main policy areas are Healthcare and Finance.
Who Benefits and How
State Medicaid programs could see lower costs, Medicare Part D beneficiaries could face fewer barriers, and Drug manufacturers could face reduced risk.
Who Bears the Burden and How
Pharmacy benefit managers serving employer health plans would take on compliance duties, Pharmacy benefit managers operating in Medicare Part D would take on compliance duties, and Pharmacy benefit managers operating in Medicaid could lose revenue opportunities.
Key Provisions
- Mandates any willing pharmacy participation in Medicare Part D networks with reasonable and relevant contract terms, creates essential retail pharmacy protections for underserved areas, establishes allegation process...
- Requires PBMs in Medicare Part D to limit remuneration to bona fide service fees, mandates full pass-through of manufacturer rebates, imposes extensive annual reporting on drug costs and PBM compensation including...
- Requires extends PBM transparency and oversight requirements to employer-sponsored group health plans across PHSA, ERISA, and the Internal Revenue Code.
- Requires codifies PBM reporting and transparency requirements into PHSA Section 2799A-11 for group health plans and health insurance issuers.
- Requires codifies PBM reporting and transparency requirements into ERISA Section 726 for employer-sponsored group health plans.
Evidence Chain:
This summary is generated from the full bill text using AI analysis. Expand "Detailed Analysis" below for identified beneficiaries/burden bearers with clause-level evidence links.
At a Glance
What This Bill Does
The bill mandates any willing pharmacy participation in Medicare Part D networks with reasonable and relevant contract terms, creates essential retail pharmacy protections for underserved areas, establishes allegation process, requires PBMs in Medicare Part D to limit remuneration to bona fide service fees, mandates full pass-through of manufacturer rebates, imposes extensive annual reporting on drug costs and PBM compensation including, and requires extends PBM transparency and oversight requirements to employer-sponsored group health plans across PHSA, ERISA, and the Internal Revenue Code.
Key Policy Areas
Healthcare, Finance
Primary Purpose
The bill mandates any willing pharmacy participation in Medicare Part D networks with reasonable and relevant contract terms, creates essential retail pharmacy protections for underserved areas, establishes allegation process, requires PBMs in Medicare Part D to limit remuneration to bona fide service fees, mandates full pass-through of manufacturer rebates, imposes extensive annual reporting on drug costs and PBM compensation including, and requires extends PBM transparency and oversight requirements to employer-sponsored group health plans across PHSA, ERISA, and the Internal Revenue Code.
Policy Domains
PBM Reform Act of 2025 -- Pharmacy Benefit Manager Regulation
Identified Gains
- State Medicaid programs
- Medicare Part D beneficiaries
- Drug manufacturers
- Independent and community retail pharmacies
- Retail community pharmacies serving Medicaid patients
Identified Costs
- Pharmacy benefit managers serving employer health plans
- Pharmacy benefit managers operating in Medicare Part D
- Pharmacy benefit managers operating in Medicaid
- Pharmacy benefit managers in Medicare Part D
- PBMs serving group health plans under PHSA
Sponsors
Legislative Progress
In CommitteeMr. Carter of Georgia (for himself, Mrs. Dingell, Mr. Murphy, …
Referred to the Committee on Energy and Commerce, and in …
Introduced in House
Stakeholder Effects
cui bono?How this legislation distributes effects. Mention counts reflect frequency, not effect magnitude.
Non-retail pharmacies (mail-order, specialty, PBM-affiliated), PBM-affiliated pharmacies, PBM-affiliated pharmacies (mail-order, specialty)
340B covered entities (safety-net hospitals, clinics), Essential retail pharmacies in underserved areas, Independent and community retail pharmacies
Benefits brokers and consultants receiving PBM compensation, Health insurance issuers, Health insurance issuers offering group coverage
PDP sponsors (Medicare Part D plan sponsors) faces effects in multiple directions
CMS (survey implementation), Centers for Medicare & Medicaid Services, Department of the Treasury/IRS
Positive-direction: State Medicaid programs
Negative-direction: CMS (survey implementation), Centers for Medicare & Medicaid Services, Department of the Treasury/IRS
Employers sponsoring ERISA health plans, Employers sponsoring group health plans, Group health plan sponsors
Medicaid beneficiaries, Medicare Part D beneficiaries
Bill Structure & Actor Mappings
Who is "The Secretary" in each section?
- "cms"
- → Centers for Medicare & Medicaid Services
- "pbm"
- → Pharmacy benefit manager
- "pdp_sponsor"
- → Prescription Drug Plan sponsor under Medicare Part D
- "the_secretary"
- → Secretary of Health and Human Services
Key Definitions
Terms defined in this bill
A fee reflecting fair market value for an itemized service actually performed, must be a flat dollar amount, and cannot be based on drug price, rebate amounts, coverage/formulary decisions, or volume of referrals
Entity that provides pharmacy benefit management services including processing claims, developing formularies, negotiating rebates, managing pharmacy networks, or making payment for covered Part D drugs
A retail pharmacy that is not a PBM affiliate and is located in a medically underserved area, or a rural area with no other pharmacy within 10 miles, suburban within 2 miles, or urban within 1 mile
Any entity that directly or indirectly owns, is owned by, controls, or is controlled by a PBM or PDP sponsor, or acts as contractor/principal/agent performing PBM functions
A model where pharmacy payments are limited to ingredient cost plus professional dispensing fee, passed through entirely to the dispensing pharmacy, with PBM compensation limited to fair-market-value administrative fees
A drug manufacturer, distributor, group purchasing organization, or any entity that receives compensation or remuneration related to drugs covered by a group health plan
We use a combination of our own taxonomy and classification in addition to large language models to assess meaning and potential beneficiaries. High confidence means strong textual evidence. Always verify with the original bill text.
Learn more about our methodology