New year, continued legislation against PBMs

Congress may not agree on whether or not to extend Affordable Care Act enhanced subsidies, but they sure do seem to agree on not liking PBMs.

Pharmacy benefit managers got a special shout-out in a recent bipartisan spending deal, which called for overhauling how the system currently works. The bill passed in the House on Jan. 22.

One element of the bill, led by Sens. Bill Cassidy (R-La.) and Bernie Sanders (I-Vt.), would prevent payments to PBMs from drug rebates, something PBMs have been criticized for—and sued over—in the past. Perhaps in anticipation of continued pushback against rebates, Cigna’s PBM Express Scripts also eliminated them last November. Previously, CVS’s Caremark had moved to a cost-based model in December 2023, and UnitedHealth Group’s Optum Rx introduced a similar reimbursement model in March 2025.

Similar reform was included in a prior December 2024 spending bill that fell apart after alleged pressure from then-President-elect Donald Trump and unofficial advisor Elon Musk.

Industry response. Perhaps unsurprisingly, PBMs aren’t exactly pleased to be a feature of the spending bill. PBM trade group Pharmaceutical Care Management Association (PCMA), in particular, said it contradicts pushes from the Trump administration to make drug prices cheaper.

According to a Jan. 20 statement from PCMA President and CEO David Marin, the bill “undermines the work President Trump is doing to hold drug companies accountable” and “means employers providing pharmacy benefits would be forced into adopting a single, one-size-fits all system, limiting negotiating power and making prescription drugs more expensive.”

PCMA has also invested heavily in lobbying and supporting legislation that supports its mission, with Stat reporting the organization increased spend 71% in the first three months of 2024 compared to 2023 (from $2.8 million to $4.8 million). By the end of 2024, PCMA had dumped $18 million into lobbying efforts, according to Axios.

A shift underway? Before this latest legislation, however, alternative PBMs have been emerging with more vigor in an effort to shake up the landscape.

While the passage of this bill wouldn’t break up the Big 3 entirely, David Reissner, group director of client engagement at communications agency VML Health, told us in an email Caremark, Express Scripts, and Optum Rx “will need to significantly adjust their business model and uncover alternative ways to generate revenue while facing increased scrutiny in the process.”

On top of federal legislation, this latest bill goes hand in hand with similar pushes to break up vertical integration among the Big 3 on the state level, as they also have stakes in insurers, pharmacies, and hospitals.

“The PBM industry is undergoing a transformative period driven by a clear mandate for transparency,” Reissner said. “This will undoubtedly reshape market dynamics, create new challenges for incumbents, and open tangible opportunities for innovative models to secure a dominant position.”