PBM Reform Act of 2025
Sponsored By: Representative Carter (GA)
Introduced
Summary
Greater PBM transparency and tighter contract rules would require pharmacy benefit managers (PBMs) to disclose detailed per‑drug revenues and rebates, protect small "essential" retail pharmacies, and change Medicaid and group plan payment rules across the drug supply chain. The bill would layer reporting, audit rights, pass‑through pricing, and enforcement across Medicare Part D, ERISA/group plans, and Medicaid to spotlight hidden payments and affiliate flows.
Show full summary
- Patients and community pharmacies: Would create an "essential retail pharmacy" label for pharmacies in underserved areas and require network access standards and biennial public data starting in 2028, helping small pharmacies show reimbursement and cost differences to plans.
- PBMs, plans, and auditors: Would force PBMs to adopt flat bona fide service fees, disclose per‑drug claims, rebates, retained revenue, and affiliate dispensing shares, and give sponsors audit rights and remedies for improper remuneration.
- States and Medicaid programs: Would require monthly national acquisition‑cost surveys, ban spread pricing in State Medicaid contracts, and mandate pass‑through pricing with itemized reporting and penalties for false data.
*Would increase federal spending for implementation by about $336 million in FY2025 and fund ongoing oversight including a $9 million annual IG appropriation.*
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Bill Overview
Analyzed Economic Effects
8 provisions identified: 8 benefits, 0 costs, 0 mixed.
More pharmacy choice in Medicare
If enacted, Medicare drug plans would have to let any pharmacy join the network if it meets standard terms, starting in 2029. HHS would set what counts as reasonable contract terms after an information request by April 1, 2027 and final standards by April 2028. Starting in 2028, HHS would list "essential retail pharmacies" in underserved areas or where no other pharmacy is nearby and publish comparisons at least every two years. Plans must report affiliate pharmacy lists starting in 2028 and pharmacy fees starting in 2027. By January 1, 2028, pharmacies could file standardized allegations if a plan breaks the contract‑term rules, and HHS could impose sanctions. MA‑PD plans would also face stronger enforcement for contract‑term violations starting in 2028.
Funding to enforce PBM transparency
If enacted, Congress would provide $188 million to CMS in fiscal year 2025 to carry out pharmacy access, standards, enforcement, and PBM oversight, available until spent. It would also provide $113 million to CMS and $20 million to the HHS Inspector General in fiscal year 2025 for PBM transparency and oversight, available until spent. MedPAC would receive $1 million in fiscal year 2025 to support its PBM reports.
Limits on PBM profits in Medicare
If enacted, starting in 2028 PBMs in Part D could be paid only flat, fair‑market‑value service fees, not other revenue, with narrow exceptions. PBMs would have to return any prohibited payments and ensure affiliates do the same. Contracts would have to make PBMs repay a plan for fines tied to duties the PBM handled. Part D plan sponsors would also have to certify compliance each year and return any PBM disgorged money they receive as required.
More Medicare PBM reporting and audits
If enacted, PBMs would have to send a free, machine‑readable report to the Part D plan and HHS each year by July 1 starting in 2028. Reports would show per‑drug prices, rebates, pharmacy payments, and totals, plus extra details when the PBM has pharmacy affiliates. PBMs would have to report when a brand or reference biologic gets better coverage than generics or biosimilars and explain why. Within 30 days of signing, PBMs would have to tell the plan about drug‑maker contracts that tie payments to coverage or formulary choices. Plans could audit PBMs at least once a year and get all needed records, including affiliate data. PBMs would also have to define pricing terms clearly and provide a WAC‑based equivalent for any other pricing benchmark.
Medicaid PBM pass‑through pricing rules
If enacted, states would have to use pass‑through pricing in Medicaid PBM and managed‑care contracts starting 18 months after enactment. Payments would be limited to ingredient cost plus a professional dispensing fee at least equal to the State plan fee, and passed through to the dispensing pharmacy, with only fair‑market‑value admin fees allowed. Spread pricing could not be used for federal matching. PBMs would have to give itemized per‑drug cost and payment data on request. The bill would also define "pharmacy benefit manager" for Medicaid to cover entities that negotiate drug prices or manage benefits, even if they work through intermediaries.
New PBM transparency for employer plans
If enacted, PBMs that serve employer health plans would have to send plans plain, machine‑readable drug reports at least every 6 months. Plans could ask for quarterly reports at the same cost. HHS would set standard forms within 18 months and machine‑readable formats by June 1, 2027. Starting with plan years that begin 30 months after enactment, plans would have to give participants a short plan summary and, on request, claims‑level details showing what the PBM and pharmacy were paid. Plans and PBMs would have to report high‑spend drugs (over $10,000 or the top 50 by spend) and disclose incentives and pricing at any affiliated pharmacies. Contracts could not block or delay required data sharing, and large employers could opt in to get full PBM reports each year.
Confidential tips and oversight on PBMs
If enacted, HHS would run a confidential tip line to report PBM violations, with anti‑retaliation protections. HHS could share reports with oversight bodies but could not publicly reveal who the parties are or specific contract prices. HHS would publish an enforcement report within 2 years and at least every 2 years after. MedPAC would report to Congress on PBM agreements after it receives data, with a final report 2 years later. GAO would study Part D payment structures and report within 2 years of enactment.
Tax enforcement could extend to PBMs
If enacted, tax penalty rules would also apply to PBMs when employer‑plan PBM reporting rules apply. The bill would also clarify a tax‑code section so these PBM rules are not exempted. This aims to back up the employer plan transparency rules with tax enforcement.
Sponsors & CoSponsors
Sponsor
Carter (GA)
GA • R
Cosponsors
Dingell
MI • D
Sponsored 7/10/2025
Murphy
NC • R
Sponsored 7/10/2025
Ross
NC • D
Sponsored 7/10/2025
Arrington
TX • R
Sponsored 7/10/2025
Harshbarger
TN • R
Sponsored 7/10/2025
Gonzalez, V.
TX • D
Sponsored 7/10/2025
Allen
GA • R
Sponsored 7/10/2025
Krishnamoorthi
IL • D
Sponsored 7/10/2025
Rose
TN • R
Sponsored 7/10/2025
Tran
CA • D
Sponsored 7/10/2025
Malliotakis
NY • R
Sponsored 7/10/2025
Khanna
CA • D
Sponsored 7/14/2025
Landsman
OH • D
Sponsored 7/15/2025
Correa
CA • D
Sponsored 7/16/2025
Fleischmann
TN • R
Sponsored 7/16/2025
Auchincloss
MA • D
Sponsored 7/21/2025
Bishop
GA • D
Sponsored 7/21/2025
Harris (MD)
MD • R
Sponsored 7/25/2025
Norman
SC • R
Sponsored 7/25/2025
Subramanyam
VA • D
Sponsored 7/25/2025
McCormick
GA • R
Sponsored 7/29/2025
Weber (TX)
TX • R
Sponsored 8/12/2025
Miller-Meeks
IA • R
Sponsored 8/15/2025
Tokuda
HI • D
Sponsored 8/26/2025
Budzinski
IL • D
Sponsored 9/2/2025
Perez
WA • D
Sponsored 9/2/2025
Flood
NE • R
Sponsored 9/3/2025
Moore (NC)
NC • R
Sponsored 9/8/2025
Mann
KS • R
Sponsored 9/8/2025
Bresnahan
PA • R
Sponsored 9/8/2025
Comer
KY • R
Sponsored 9/9/2025
McBride
DE • D
Sponsored 9/18/2025
Langworthy
NY • R
Sponsored 9/30/2025
Franklin, Scott
FL • R
Sponsored 9/30/2025
Goldman (TX)
TX • R
Sponsored 10/3/2025
Johnson (TX)
TX • D
Sponsored 10/3/2025
Cammack
FL • R
Sponsored 10/8/2025
Tlaib
MI • D
Sponsored 10/10/2025
Craig
MN • D
Sponsored 10/17/2025
Cloud
TX • R
Sponsored 10/21/2025
Calvert
CA • R
Sponsored 10/21/2025
Harder (CA)
CA • D
Sponsored 10/24/2025
Mfume
MD • D
Sponsored 10/28/2025
Owens
UT • R
Sponsored 10/31/2025
Kiggans (VA)
VA • R
Sponsored 10/31/2025
Houlahan
PA • D
Sponsored 11/4/2025
Peters
CA • D
Sponsored 11/7/2025
Sessions
TX • R
Sponsored 11/12/2025
Messmer
IN • R
Sponsored 11/12/2025
Scholten
MI • D
Sponsored 11/12/2025
Sewell
AL • D
Sponsored 11/17/2025
Goodlander
NH • D
Sponsored 11/17/2025
Barrett
MI • R
Sponsored 11/20/2025
Biggs (SC)
SC • R
Sponsored 11/21/2025
Clarke (NY)
NY • D
Sponsored 11/28/2025
Davids (KS)
KS • D
Sponsored 12/1/2025
Rogers (KY)
KY • R
Sponsored 12/3/2025
Mackenzie
PA • R
Sponsored 12/9/2025
Wilson (SC)
SC • R
Sponsored 12/9/2025
Vasquez
NM • D
Sponsored 12/9/2025
Bentz
OR • R
Sponsored 12/9/2025
Joyce (PA)
PA • R
Sponsored 12/16/2025
Babin
TX • R
Sponsored 12/16/2025
Davis (NC)
NC • D
Sponsored 12/16/2025
Dunn (FL)
FL • R
Sponsored 12/19/2025
Van Drew
NJ • R
Sponsored 1/8/2026
Lawler
NY • R
Sponsored 1/12/2026
Olszewski
MD • D
Sponsored 1/20/2026
Van Orden
WI • R
Sponsored 1/21/2026
Roll Call Votes
No roll call votes available for this bill.
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