By Daisy Brown, Legislative Liaison, TSCL
Do you remember when the government partially shut down back in February, when Congress couldn’t come up with a deal to keep the lights on amid a political fight over funding for the Department of Homeland Security? Well, the law eventually passed to end that impasse, the 2026 Consolidated Appropriations Act, also made some pretty big changes affecting Medicare Part D.
The Act set forth new regulations governing the behavior of Pharmacy Benefit Managers (PBMs), who are like middlemen between insurers, pharmacies, and drug manufacturers. Criticized for lack of transparency and helping drive up costs for patients, PBMs negotiate drug prices, manage lists of covered medications, and process pharmacy claims for patients and insurers.
Key provisions for PBMs in the 2026 Consolidated Appropriations Act include requiring PBMs to provide detailed, semiannual reporting on spending, rebates, and spread pricing arrangements. It prohibits PBMs from receiving Medicare Part D payments for anything other than market-value fees for services actually performed starting in 2028, and forces Part D sponsors to allow any pharmacy that meets standard contract terms to participate in their network starting in 2029.
It looks like these changes will likely benefit seniors over the long haul, with some power in the healthcare system shifting from middlemen and drug manufacturers back to the pharmacies. “The abuses of the dominant PBM middlemen are widely recognized, and this landmark federal action reflects the broad, bipartisan commitment to confront and remedy them,” said Steven C. Anderson, president and CEO of the National Association of Chain Drug Stores, in a statement about the changes. “This is the most important federal achievement yet for PBM reform, and it will build and sustain momentum for further reforms where needed.”
