The government is forcing PBMs to be more transparent, but will reforms make a difference?

Pharmacy benefit managers (PBMs) have taken a number of steps recently to make their practices more transparent, such as eliminating rebates or shaking up pricing models.

The moves follow intense public scrutiny over evidence that PBMs’ outsized—and opaque—influence in the pharmaceutical supply chain may play a large role in keeping drugs unaffordable for many Americans.

But experts told Healthcare Brew it’s unclear whether such changes will lead to any substantial improvements in drug affordability anytime soon.

PBMs are often called “middlemen” because they operate between drug manufacturers and health insurance plans. They negotiate with the manufacturers to create formularies, or lists of drugs that insurers agree to cover. They also help health plans adjudicate prescription claims, reimburse pharmacies for dispensed prescriptions, and decide which pharmacies are in network for a specific plan.

However, PBMs often consider the details of their contracts with drugmakers as proprietary, which creates opacity for the health plans they work with. Because the plans don’t have insight into how PBMs negotiate prices for drugs included on their formularies, it makes it hard to know whether they’re getting a good deal—unless they’re one of the health plans like Aetna, Cigna, or UnitedHealthcare that are vertically integrated with a PBM.

A bird’s-eye view of PBM changes

In the last few years, the FTC has sued the three largest PBMs—CVS Caremark, Express Scripts, and Optum Rx—alleging they conspired to boost their profits by inflating insulin costs. The House oversight and government reform committee has also launched an investigation into PBMs.

As of July, the FTC has reached settlements with both Express Scripts and Caremark regarding the 2024 insulin lawsuit. Each settlement requires the PBMs to make changes such as increasing transparency in the data they provide to health plans. Optum has yet to reach a final settlement with the FTC, though it reached a tentative proposed consent agreement in June.

The most significant pressure involved Congress passing a set of reforms in February. They were part of the Consolidated Appropriations Act of 2026 and required PBMs to make a number of changes to their business practices, including passing through 100% of rebates to their employer health plans and providing more data to health plans on their contracts with drugmakers.

Rebates are what drugmakers typically pay a PBM in exchange for putting their drug on formularies. Rebate amounts are typically considered trade secrets, so it’s often difficult to gauge how much PBMs profit from them, further obscuring the drug pricing process. However, the Department of Labor in January proposed a rule that would require PBMs to disclose rebates.

The Congressional Budget Office estimated the reforms would lead to a $2.1 billion federal deficit reduction by 2035.

Optum, a Big 3 PBM owned by UnitedHealth Group, announced plans in March 2025 to move to a cost-based reimbursement model by 2028, according to a company press release. The model involves reimbursing pharmacies for the cost of acquiring a medication, plus a dispensing fee that covers things such as the labor it takes to stock and dispense prescriptions.

Then in October 2025, Express Scripts, another Big 3 PBM owned by insurance giant Cigna Healthcare, announced a plan to eliminate rebates. Spokesperson Justine Sessions told Healthcare Brew that the company plans to adopt the rebate-free model “for its fully insured commercial business beginning in 2027.”

In response to questions about PBMs’ influence on drug costs, Sessions said Express Scripts acknowledges affordability is a big problem, but said PBMs don’t set drug prices. Instead, she said their “role is to help counter those pressures by negotiating discounts, creating competition, improving access, and helping employers and patients get greater value from their pharmacy benefits.”

The Pharmaceutical Care Management Association, a trade group representing PBMs, did not respond to Healthcare Brew’s request for comment.

Remaining challenges

While federal pressure is “definitely forcing” the PBMs to make changes, it’s unclear how significant those changes will be, according to Geoffrey Joyce, director of health policy at the University of Southern California Schaeffer Center for Health Policy and Economics.

For instance, even though PBMs will be forced to pass through rebates instead of keeping them as profit, they could simply shift their business models to bring in revenue from elsewhere, Joyce said. Instead of rebates, they could charge higher fees. PBMs typically charge health plans fees, such as an administrative fee for every prescription claim processed.

“They get smart. They have smart lawyers, and I’m a little worried we’re going to move from a black box of rebates to a black box of fees,” Joyce said.

While PBMs may evolve their strategies quickly, regulation is unlikely to keep pace, according to Matthew Fiedler, a senior fellow with Brookings’s Center on Health Policy. There is some interest from lawmakers to enact further PBM reform, such as forcing them to divest their pharmacies, he said. However, he’d “be surprised if anything else became law in the near term.”