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The Centers for Medicare & Medicaid Services is giving employers and benefits advisors a sneak peek at how the new federal pharmacy benefit manager rules for self-insured employer health plans might work.
CMS staffers are showing how they think about PBM regulation in a new request for information posted Wednesday. The CMS staffers want to use the answers they get to implement a new, related set of rules for PBM efforts to serve Medicare Part D prescription drug plans.
Both the employer plan PBM rules and the Medicare plan PBM rules were created by sections of the Consolidated Appropriations Act, 2026, a big package of legislation that became law in February.
PBMs that serve Medicare plans will have to start complying with their new rules by July 1, 2028, officials say in the information request notice.
What it means: CMS can implement the Medicare plan PBM rules on its own. The U.S. Department of Health and Human Services agency will have to work with the Internal Revenue Service and the U.S. Labor Department's Employee Benefits Security Administration to implement the new employer plan PBM rules.
But the new request for information could provide clues about how CMS sees PBM issues.
The CAA, 2026 pharmacy benefit manager provisions: The CAA, 2026 package ended up including two sets of PBM provisions.
One set requires PBMs that serve Medicare Part D prescription drug plans to pass any rebates or other discounts on to the patients, limits the PBMs to receiving flat-dollar service fees, requires the PBMs to let patients use any pharmacies willing to accept the PBMs' prices, and requires the PBMs to provide detailed PBM compensation and operations reports.
The other set of PBM provisions requires PBMs that serve self-insured employer plans to pass any rebates on to the employers and to provide detailed compensation and operations reports.
The Medicare plan PBM rules request for information: The new RFI will officially appear in the Federal Register Thursday and responses will be due around July 15.
Some of the questions in the RFI concerns definitions, such as details about what exactly a PBM is and what a PBM does.
"Are there categories of entities that commonly provide functions through an intermediary on behalf of a [prescription drug plan] sponsor or prescription drug plan?" officials ask.
For each category of intermediary, officials ask for any available information about ownership of those intermediaries, the kinds of contractual relationships that government the relationship between an intermediary and a PBM, the services that an intermediary might perform, the types of payments that the intermediary might receive, and the sources of the intermediary's payments.
Officials also ask about whether and how the payments an intermediary receives might vary.
In another section of the RFI, CMS officials ask about the definition of the word "affiliate," in connection with a PBM, and what types of entities might or might not be seen as an affiliate of a PBM. Officials list entities such as group purchasing organizations, payment facilitators, pharmaceutical relabelers, and data vendors in that question.
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