Increased security on pharmacy benefit managers (PBMs) as well as state and federal action to rein in their influence could have impacts across a variety of stakeholders in the health care system, including patients, PBMs, pharmacies, health care plans and manufacturers.
PBMs provide administrative services for prescription drug plans and act as an intermediary between health insurers, pharmacies and drug manufacturers. Their influence has expanded significantly to include claims processing, formulary management, and contracting with manufacturers and pharmacies.
In addition, the PBM market has consolidated into a handful of large, vertically integrated entities that dominate the market, which has attracted increased scrutiny from policymakers at both the state and federal levels. Earlier this year, Arkansas became the first state to ban PBM-owned pharmacies, although the legislation is under review. Several other states have considered or enacted similar restrictions, including Indiana, Louisiana, New York, Texas and Vermont.
Proposed federal legislation has sought to require PBMs to divest from pharmacy ownership, and President Trump has signaled renewed interest in the role of intermediaries.
Critics say PBMs inflate drug costs through spread pricing and rebates, restrict patient choice by steering them to affiliated pharmacies and favoring higher-rebate drugs, and harm independent pharmacies by under-reimbursing them.
Avalere Health studied how federal and state efforts to oversee PBM pharmacy ownership could affect stakeholders across the health care system. For patients, changes to ownership and operational practices could disrupt access to in-network pharmacies, timely receipt of specialty medications and consistency of medication management and support services, the study said. Patients with complex conditions could be especially impacted if PBM-pharmacy divestiture efforts result in fewer specialty or retail pharmacies in some areas.
PBMs are likely to face ownership changes under the legislative actions, resulting in uncertainty across the ecosystem. Pharmacy-affiliated PBMs will likely see revenue and operational impacts, and mail-order services could be disrupted, said the report. Non-affiliated PBMs, while not directly impacted by the proposed legislation, are likely to face new competitive dynamics, said Avalere.
For independent pharmacies, rules requiring divestiture or closure of affiliated pharmacies could create new opportunities, but that will depend on contracting dynamics, reimbursement rates and their capacity to absorb additional volume.
Independent specialty pharmacies also could see new opportunities to absorb displaced patients if PBM-affiliated specialty pharmacies experience ownership changes. PBM-affiliated pharmacies accounted for two-thirds of specialty drug prescription revenue in 2024.
Health plans could face operational and contracting challenges under the proposed legislation, with restrictions on mail-order pharmacies and closures of retail and specialty pharmacies potentially affecting network adequacy and patient access. Reimbursement dynamics also could shift during contract renegotiations.
Finally, manufacturers could face logistical challenges, including potential disruptions to their contracting or formulary strategies. Alternative data sources may be needed to track outcomes and maintain visibility into patient experiences.
“Given state and federal interest in PBM oversight and reform, stakeholders should remain vigilant of the downstream effects of legislation like PBM-pharmacy co-ownership prohibitions,” said the report. “Specifically, if the federal injunction on AR Act 624 is lifted, there will be both significant change for drug distribution channels in Arkansas and across the nation as consequences reverberate across national pharmacy and PBM chains, and as similar state-level legislation is possibly considered.”
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