For years, Congress has signaled its intention to crack down on Pharmacy Profit Managers, the middlemen below hearth for his or her vertical integration with insurers and their position in rising drug prices.

This week, it lastly occurred by means of the Consolidated Appropriations Act of 2026, giving rise to it employer teams, together with the Purchaser Enterprise Group on Well being (PBGH) and the ERISA Business Committee, to applaud its passage.

“Taken collectively, the bipartisan well being care reforms on this invoice will scale back well being care prices for each employers and workers, introduce new legal responsibility for PBMs, and supply purchasers with an unprecedented degree of transparency of their pharmacy profit plan,” in accordance with a press release from PBGH.

However the actuality is extra difficult. Whereas it’s true that employers have made large beneficial properties, this is among the most necessary components of the regulation – decoupling PBM compensation from the value of a drug in Medicare Half D – eluded employer teams. It is a provision within the new regulation that solely applies to Medicare Half D, mentioned Jesse Dresser, companion in Frier Levitt’s Life Sciences division.

In Medicare Half D, unfold pricing was additionally prohibited as a result of PBMs can not generate income related to the price of the drug, Dresser mentioned. Unfold pricing happens when a PBM costs a well being plan extra for a drug than it pays the pharmacy and retains the distinction as revenue. The adjustments will come into impact in 2028.

Employers, in the meantime, weren’t banned from unfold pricing, famous Shawn Gremminger, president and CEO of the Nationwide Alliance of Healthcare Purchaser Coalitions. In addition they didn’t get the “long-term demand” to make PBMs fiduciaries for his or her purchasers, which might require PBMs to behave in the most effective monetary pursuits of employers.

Nonetheless, this could not detract from what the regulation accomplishes, as it’s “an enormous deal and can meaningfully change the way in which PBMs function within the industrial area,” Gremminger mentioned.

If checklist value decoupling, a ban on unfold pricing, and PBMs not changing into fiduciaries for patrons in the end failed within the closing move, what beneficial properties had been made?

What the regulation does imply for employers is a requirement for PBMs to offer extra detailed reporting to plan sponsors, corresponding to a listing of coated drugs disbursed, prescriptions disbursed by affiliated pharmacies, and details about biologics and biosimilars. As well as, PBMs are mandated to move on any rebates, rebates, reimbursements and different funds they obtain for drugs on to employers or group well being plans.

“After eight years, ERIC-led reforms to the PBM trade, which carry higher accountability and transparency, have met their goal, and the end result can be decrease drug prices for greater than 160 million People who get their medical health insurance by means of a job,” James Gelfand, president and CEO of the ERISA Business Committee, mentioned in a press release.

This does put PBMs on the trail to extra transparency, however the battle has not been received.

As Wendell Potter famous in his e-newsletter, employers can truly get a few of what they need by means of a rule the Division of Labor not too long ago proposed. The rule would require PBMs to reveal all rebates and different funds from producers to employer-sponsored well being plan fiduciaries, together with any offsets associated to the distinction between plan funds and pharmacy reimbursements. It additionally permits fiduciaries to manage these disclosures and gives safety if PBMs fail to conform.

“With the brand new Consolidated Appropriations Act of 2026, together with the proposed laws from the Division of Labor, I feel there can be some extra protections, extra aid aimed toward compelling the discharge of sure info,” Dresser mentioned.

However in accordance with Gremminger, whereas the Division of Labor’s proposed rule and the Consolidated Appropriations Act of 2026 give patrons “unprecedented transparency” about PPE, employers nonetheless will not have all the pieces they’re searching for.

“Even after each the laws and the regulation are applied, PBMs will nonetheless be allowed to have interaction in unfold pricing and tie their reimbursements to the value of medicine within the industrial market. PBMs will nonetheless not be authorized fiduciaries,” Gremminger mentioned. “The occasions of the previous week are an enormous step ahead, however way more must be achieved.”

Dresser additionally famous that it’s attainable that the Division of Labor’s proposed rule might change over time, particularly contemplating it was launched the identical week because the Consolidated Appropriations Act of 2026.

“A part of what they need to do within the new laws is already decided by regulation and in addition requires the introduction of laws aimed toward implementing and implementing these new guidelines,” he mentioned. “So I feel there’s a chance that this specific model of the Division of Labor’s proposed laws could not transfer ahead, however as an alternative be transformed into one thing that could be extra in keeping with the not too long ago enacted regulation.”

He added that it’s unlikely that future iterations of the DOL rule will embody a ban on unfold pricing, as this can doubtless require congressional motion. Nonetheless, it’s attainable that this may increasingly end result from company enforcement actions. He pointed to the latest FTC settlement with Categorical Scripts over insulin, wherein Categorical Scripts agreed to a collection of adjustments, together with transferring away from a rebate mannequin.

Firms that serve employers are additionally applauding the efforts made to rein in PBMs, together with Carrum Well being.

“We welcome these developments in addressing PPE pricing and compensation as it’ll create higher transparency for employers,” mentioned Doug Cole, vice chairman of Well being Plan Partnerships at Carrum Well being.

In the meantime, AJ Loiacono, CEO of Judi Well being (a tech-based PBM, previously Capital Rx), agrees that it is a large step ahead, however acknowledges that extra must be achieved. For instance, the regulation doesn’t cowl PBMs that ship sufferers to affiliated specialty pharmacies or vertical integration. Judi Well being profiles itself as a clear PBM.

“If PBMs personal mail-order and specialty pharmacies, they’ve monetary incentives to steer sufferers to these channels – typically at the next value to the plan. Better transparency in pricing and use of affiliated pharmacies is an efficient begin, however in the end structural separation could also be vital,” he mentioned.

In different phrases, Loiacono means that PBMs must be cut up in order that an insurance coverage firm, a PBM and a pharmacy shouldn’t have the identical dad or mum firm, as is the case with many main PBM gamers in the present day. That could be the longest shot of all.

Picture: cagkansayin, Getty Photos