Pharmacy benefit managers are no strangers to criticism. What is different in 2026 is the intensity, the bipartisan alignment and the regulatory follow-through.
In recent weeks, Congress, federal regulators and the Trump administration have all taken aim at PBMs, signaling that long-debated reforms may finally gain traction. For hospital and health system leaders, the message is clear: pharmacy contracting and drug pricing strategy are about to get more complicated.
The U.S. Department of Labor has finalized a rule that increases scrutiny of PBM consultants who advise employer-sponsored health plans. Under the rule, certain consultants may be treated as fiduciaries under the Employee Retirement Income Security Act if they exercise discretion over pharmacy benefit decisions. That designation brings stricter conflict-of-interest and disclosure requirements.
The change is designed to address concerns that consultants have steered employers toward PBM arrangements that maximize rebates and fees rather than lower total drug spending. For health systems that sponsor self-funded plans, the rule elevates compliance risk and demands closer oversight of PBM and consultant relationships.
On Capitol Hill, lawmakers are revisiting PBM reforms as part of the Consolidated Appropriations Act for fiscal 2026. Proposals under discussion would expand transparency requirements, restrict spread pricing in Medicaid managed care and require more direct rebate pass-through to plans or patients. Several of these provisions have stalled in prior years, but renewed bipartisan frustration is giving them new life.
At the same time, structural reform is back on the table. Sens. Elizabeth Warren, D-Mass., and Josh Hawley, R-Mo., have introduced legislation that would force large, vertically integrated PBMs to divest from affiliated insurers and pharmacies. Supporters argue that consolidation allows dominant PBMs to favor their own entities and disadvantage independent and hospital-based pharmacies. The proposal reflects rare cross-party agreement on PBM market power, even if its path forward remains uncertain.
House lawmakers are also pressing for deeper PBM changes as they evaluate President Donald Trump’s drug pricing agenda. During recent hearings, members questioned whether the administration’s broader plan sufficiently addresses rebate structures, spread pricing and prior authorization practices that providers say drive up costs and delay care. Physician and pharmacy groups continue to raise concerns about reimbursement pressure and patient access barriers tied to PBM policies.
For hospitals, this debate is not abstract. PBM practices influence reimbursement for hospital-owned pharmacies, formulary access for clinicians and the total cost of care for employed workforces. They also shape patient affordability at discharge, particularly for specialty medications.
The convergence of regulatory action and bipartisan legislative momentum suggests that incremental tweaks may give way to more meaningful change. Even if sweeping breakups stall, expanded reporting, fiduciary standards and rebate reforms appear increasingly likely.
Key takeaways for hospital and health system leaders
- Reassess PBM and consultant contracts, especially if your organization sponsors a self-funded plan. Ensure fiduciary responsibilities, fee disclosures and rebate arrangements can withstand heightened scrutiny.
- Model financial exposure. Changes to spread pricing or rebate pass-through rules could materially affect pharmacy margins and employee health plan costs.
- Align pharmacy strategy with advocacy. Policymakers are actively seeking examples of how PBM practices affect patient access and provider sustainability. Health systems have an opportunity to shape the debate with data.
PBM reform has surfaced before, only to fade. This time, however, bipartisan legislation, new federal rules and White House engagement are converging. For hospital leaders, preparation, not prediction, will be the safer course.