Issue Brief by Policy Analyst, Erin Twomey Partin | etpartin@csg.org

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The United States is the only country in the world that uses pharmacy benefit managers (PBMs), which serve as intermediaries between pharmacies, insurers, and drug manufacturers. PBMs emerged in the 1960s to assist health plans and pharmacies with managing and processing drug benefits through negotiations with drug manufacturers and pharmacies, with the stated objective of helping manage administrative processes and costs (insurance companies or government programs). Today, PBMs manage prescription drug plans for more than 289 million Americans.¹ and have become a significant player in the pharmaceutical supply chain, with deep involvement in evaluating and setting drug coverage preferences for health plans.²

The largest PBMs have grown into vertically integrated organizations with operations spanning multiple points in the drug supply chain—from health plans to pharmacies—contributing to increased negotiating capacity.³ streamlined claims management, and patient adherence initiatives.⁴ Meanwhile, drug prices in the United States consistently exceed those in comparable countries.⁵ Although PBMs are not the only actor within the drug market that could contribute to higher costs, their role in drug pricing has prompted policymakers on both sides of the aisle to examine how PBM business practices might be regulated to reduce costs while preserving administrative efficiencies associated with PBM review and approval processes.

State policymakers continue to explore PBM regulation, and the 2026 legislative session is expected to bring renewed attention to the issue. Health insurance premiums are projected to increase, with average Affordable Care Act Marketplace plan costs anticipated to rise by approximately 26 percent.⁶ Combined with current inflation trends, these cost pressures may further affect individuals’ ability to afford and access healthcare.⁷ Recent polling indicates that affordability challenges are being felt by households, with one in five respondents reporting difficulty paying for at least one prescription in the past three months. Further, nearly half of the respondents expressed concern for their ability to afford healthcare in 2026.⁸

PBM Functionality

Processing Claims and Managing Drug Utilization

When pharmacies submit drug claims, a PBM processes those claims to determine if a patient’s health plan will cover the cost of the drug. Online, real-time drug claim processing was first introduced in 1987. Since then, PBMs have established systems for online claims processing and two-way communication with pharmacists, rendering the process paperless and virtually automatic.⁹ A pharmacist can submit a claim and know almost immediately if the PBM will cover the cost. The PBM system will cross-reference the drug against the patient’s health plan and determine coverage and cost-sharing.¹⁰

Through the claims process, PBMs play a vital role in managing drug utilization and preventing unsafe drug usage. PBMs use prior authorization, step therapy (trying lower cost treatment options first), and quantity dispensing limits to mitigate costs and reduce the likelihood of overuse.¹¹ These measures work in tandem with the claims system and network of pharmacies to monitor drug usage and protect patients from potential dangerous drug interactions.¹²

*PBM drug monitoring is separate from state-run Prescription Drug Monitoring Programs (PDMP). While the two operate similarly, PBM drug monitoring serves administrative needs, as opposed to PDMP data being used to support public health.

Developing Drug Formularies

PBMs function within the broader drug supply chain by managing prescription drug benefits for health plans through negotiations with drug manufacturers and pharmacies. PBMs work with drug manufacturers to develop drug formularies, which are lists of drugs a health plan will cover. Development of drug formularies involves assessing a drug’s effectiveness and overall cost.¹³ Drug manufacturers can offer rebates to decrease the cost of their drug and ensure its placement on a formulary by a benefit provider.¹⁴ PBMs then provide the formulary lists to pharmacies specifying which drugs customer health plans will cover.¹⁵

There are different types of drug formularies—open and closed—that identify prescription drugs that are covered by a participant’s particular coverage plan. PBMs often use committees comprised of physicians, pharmacists, and health care professionals to recommend drugs for each type and tier. Open formularies allow coverage for a wide range of prescriptions, usually resulting in a higher health plan cost. Closed formularies are more limited and only allow coverage for a more limited selection—usually the cheaper or more heavily discounted—drugs. In the case of a closed formulary, if a drug is not on the list, the plan will not cover it at all.¹⁶

Within both open and closed formularies, tiers break down prescription drugs into sub-groupings that specify the level of coverage a plan offers. Table 1 shows an example of formulary tiers from UnitedHealthcare. Lower tiers typically have the least cost-sharing responsibility for patients (lower out-of-pocket costs for consumers). These tiers are also lower-cost and typically include generic drugs. Conversely, the higher tiers have larger cost-sharing responsibilities for plan participants and tend to include brand-name drugs. However, as previously mentioned, drug manufacturers can offer rebates to lower the cost of their drug, which would place it on a lower tier and result in more sales for the manufacturer.¹⁷

TABLE 1. Example of Drug Formulary Tiers in Both Open and Closed Models

Drug Tier	Types of Drugs Included	Your Cost
Tier 1: Preferred Generic	Commonly used generic drugs	Lowest copay
Tier 2: Generic	Many generic drugs	Medium copay
Tier 3: Preferred Brand	Many common brand name drugs, called preferred brands, and some higher-cost generic drugs	Higher copay; Insulin drugs with $35 max copay
Tier 4: Non-preferred Drug	Non-preferred generic and non-preferred brand name drugs	Highest copay
Tier 5: Specialty Tier	Unique and/or very high-cost brand and generic drugs	Highest coinsurance

PBMs and Drug Pricing

Spread Pricing and Rebates

The influence that PBMs have on drug pricing stems from the way they generate revenue and profits. Figure 1 provides a simplified illustration of service and funding streams within the drug market. Health plans pay PBMs for administrative costs, drugs, and dispensing. PBMs then pay pharmacies for the drugs patients have purchased. The difference between the amount the health plans pay to the PBMs and what the PBMs subsequently reimburse pharmacies is called “spread pricing.”¹⁰¹

It is difficult to quantify the spread pricing for individual PBMs because the agreements between PBMs and health plans are not public. However, one study found that of the $11.8 billion spent on Medicare Part D, PBM gross profit made up 40.8 percent while pharmacy gross profits represented 17.2 percent.¹⁹ The data reflect a difference between PBM gross margins and the reimbursement levels paid to pharmacies.

FIGURE 1. The Role of Pharmacy Benefits Managers (PBMs) in Managing Prescription Drug Benefits and Flow of Funds

PBMs also generate revenue through their rebate negotiations. Similar to spread pricing practices, there is a general lack of transparency with PBM business practices surrounding rebates. PBMs are allowed to keep a portion of the rebates they negotiate, meaning the total discount is not necessarily passed on to the patient. Rebate amounts are positively correlated to a drug’s list price and utilization.²¹ This means that the more expensive a popular drug is, the higher the dollar value of the rebate will be. Consequently, some researchers and policymakers argue that because PBMs retain a portion of negotiated rebates, this structure may create financial incentives favoring higher list-price drugs with larger rebate values. While the rebate itself brings the drug price down for patients, there is the potential for drug manufacturers to raise list prices so that the net pricing, and therefore the drug company‘s gross revenue, is higher.²² In fact, a 2020 report from the USC Schaeffer Center found that a $1 rebate increase was associated with a $1.17 increase in list price.²³

The Pharmaceutical Care Management Association (PCMA) reports that PBMs save payers and patients approximately $1,154 per person annually through rebate negotiations.²⁴ Yet, compared to the global drug market, patients in the U.S. pay significantly higher prices than in other countries. According to a 2024 report to the United States Department of Health and Human Services from RAND Health Care, despite the estimated savings through PBM intervention, patients in the United States spend nearly three times as much on all drugs (brand name and generic) as patients in comparable countries.²⁵

Market Share

PBMs’ parent companies have broadened their scope and established themselves at multiple points within the pharmaceutical market to operate a more vertically-oriented business operation. A frequently cited example of this is CVS Caremark, which manages 34 percent of all prescription drug claims. Its parent company, CVS Health Corporation, also owns the leading retail pharmacy in the United States (CVS Pharmacy),²⁶ a private health insurer (Aetna),²⁷ and various other pharmaceutical actors. Known as vertical integration, this organizational structure enables PBMs and parent companies to have a strong influence and negotiating power over pricing along the supply chain.²⁸

As shown in Figure 2, three PBMs (CVS Caremark, Optum Rx, and Express Scripts) manage nearly 80 percent of prescription drug claims, and the top six PBMs (sometimes referred to as the “Big 6”) handle 94 percent of all prescription claims.²⁹ Furthermore, all but one of the “Big 6” have vertically integrated with a health insurer. All the top PBMs own mail order pharmacies, specialty drug pharmacies, and rebate aggregators, and four own health care provider groups.³⁰

FIGURE 2. Vertical Integration of the Top Six Pharmacy Benefit Managers during 2023

As a result, the “Big 6” PBMs may have the ability to structure contracts in ways that align with affiliated entities, a dynamic that some analysts suggest could influence pharmacy network participation and drug coverage decisions. PBMs generally influence pharmacy selection in two ways: by reimbursing independently owned pharmacies at lower rates than their own affiliated pharmacies,³² or by excluding independent pharmacies from a health plan’s network altogether.³³ A study published in early 2025 found clear evidence of this practice—the share of prescriptions filled at PBM-owned pharmacies was substantially higher among patients enrolled in PBM-owned health plans, compared to patients covered by other insurers.³⁴

The remaining 6 percent of the PBM market share is comprised of smaller and newer PBMs. In recent years, many PBMs in this portion of the market have taken note of policy debates surrounding the “Big 6” and altered their business models accordingly. Two examples are Rightway³⁵ and Cost Plus Drug Company,³⁶ both of which advertise having high levels of pricing transparency and limited to no conflicts of interest.

Recent State PBM Regulations

Policymakers are looking to mitigate certain PBM business practices, like patient steering and rebate retention, while still leveraging the administrative and cost reduction benefits they offer. Within the CSG South region, Alabama, Louisiana, and North Carolina now require rebates to be passed on as cost savings to patients. Other states have enacted provisions that limit PBMs’ ability to engage in spread pricing and increase transparency requirements. Utah, for example, passed a bill (House Bill 0257) this past session that forbids spread pricing and mandates rebate pass-through. Similarly, Colorado’s House Bill 25-1094 requires new transparency measures for drug pricing. More information on recent legislation from the CSG South region can be found in Table 2, and information on recent legislation from outside of this region can be found in Table 3.

TABLE 2. Recent (2024-2025) Pharmacy Benefit Legislation in CSG South States

State	Measure (Year)	Summary
Alabama	Senate Bill 0252 (2025)	This bill establishes a minimum reimbursement rate for independent pharmacies and mandates pass-through pricing of rebates.
Arkansas	House Bill 1150 (2025) Senate Bill 475 (2025)	This bill prohibits PBMs from obtaining retail pharmacy permits to prevent anticompetitive practices and increase transparency. This act regulates PSAOs.
Louisiana	House Bill 0264 (2025) Senate Resolution 209 (2025)	This legislation regulates pharmacy benefit managers by banning rebate retention and spread pricing, mandating transparent reimbursement and reporting practices, strengthening enforcement, and protecting local pharmacies and consumers from unfair PBM practices. Health to study the impacts of PBM-owned pharmacies.
Mississippi	House Bill 856 (2025)	This bill provides regulations for pharmacy practices, including PBMs and PSAOs, through the Board of Pharmacy.
North Carolina	Senate Bill 0479 (2025)	This law imposes fiduciary duties on PBMs to act in the best interest of insurers and health plans, and extends consumer protections by requiring that pharmacy rebates be passed on to consumers at the point of sale, reducing out-of-pocket costs. It also strengthens transparency through audit protections for pharmacies and price increase notifications from manufacturers.
Oklahoma	House Bill 2048 (2025) House Bill 3376 (2024)	This legislation introduced Oklahoma’s 340B Nondiscrimination Act, which prevents discriminatory reimbursement practices from health insurers, pharmacy benefits managers, and other third-party payors. Among other things, this act prohibits spread pricing, requires PBMs to disclose detailed records of their transactions, and strengthens oversight from the Oklahoma Attorney General.
Virginia	House Bill 2375 (2025) House Bill 2610 (2025) Senate Bill 875 (2025) Senate Bill 0660 (2024)	1. This legislation enhances drug price transparency through data collection and reporting, and it regulates pharmacy services administrative organizations (PSAOs). 2. The law establishes a state PBM for Virginia’s Medicaid program recipients. It also requires that the state PBM have a fiduciary duty to the Department of Medical Assistance Services, use pass-through pricing, adhere to a common formulary, and refrain from spread pricing. 3. Companion bill for HB 2610. 4. This act adds additional requirements to existing reporting requirements for insurance carriers relating to pharmacy benefits managers. The requirements are as follows: • the aggregate amount of a pharmacy benefits manager’s retained rebates • a pharmacy benefits manager’s aggregate retained rebate percentage • the aggregate amount of administrative fees received by a pharmacy benefits manager

Arkansas has taken accountability measures one step further by forbidding PBMs from owning pharmacies, limiting conflicts of interest along the supply chain, and supporting antitrust, though there have been legal challenges to this approach.³⁷ There is concern that because of the market share of the “Big 6,” forbidding PBMs from owning pharmacies could result in potential reduction in the number of available pharmacies, contributing to pharmacy deserts (census tracts with a high poverty rate and no pharmacies within 1 mile in urban areas or 10 miles in rural areas).³⁸ In addition to the economic cost of losing jobs and tax revenue.³⁹ It is estimated that about 56.1 percent of the pharmacies in pharmacy deserts are chain pharmacies,⁴⁰ many of which are PBM-owned.⁴¹ Therefore, some analysts caution that prohibitions like Arkansas’s could affect pharmacy access in certain areas unless independent pharmacies are able to fill gaps in the market.

Regulations to combat high drug prices have not been limited to PBM reforms. Policymakers recognize that there are multiple actors influencing drug costs, and while many states are reforming specific PBM regulations, some states are also looking into reforming the broader system. For example, within the CSG South region, Arkansas, Mississippi, and Virginia have turned their attention towards Pharmacy Services Administrative Organizations (PSAOs), which provide administrative support to independent pharmacies, in addition to PBM regulations. Similar to PBMs, PSAOs negotiate drug costs with manufacturers on behalf of their member pharmacies that aren’t part of a broader corporate structure.⁴² PSAOs help independent pharmacies set drug prices through negotiations with PBMs and drug wholesalers.

TABLE 3. Recent (2024-2025) Pharmacy Benefits Legislation outside of the CSG South Region

State	Measure (Year)	Summary
California	Senate Bill 41 (2025)	This bill provides for major reforms for California PBMs, banning spread pricing, mandating transparency and pass-through pricing, and prohibiting discrimination against nonaffiliated pharmacies.
Colorado	House Bill 25-1094 (2025)	This legislation aims to reduce drug costs by establishing new transparency and reimbursement requirements for pharmacy benefit managers.
Indiana	Senate Bill 140 (2025)	This act regulates PBMs by prohibiting discriminatory practices when developing pharmacy networks, though Medicaid and some state health plans are excluded.
Iowa	Senate File 383 (2025)	This act requires a review of PSAOs and the entire drug supply chain in addition to regulating PBM reimbursement practices.
Montana	House Bill 740 (2025)	This bill sets minimum reimbursement rates for independent pharmacies and aims to increase PBM transparency.
Nevada	Senate Bill 389 (2025)	This act places Medicaid pharmacy benefits under a single, state PBM.
North Dakota	House Bill 1584 (2025)	This act requires licensing for PBMs which will require application and renewal fees, and mandates PBMs to provide pharmacies with opt-in contracts.
Utah	House Bill 257 (2025)	This legislation mandates the use of pharmaceutical rebates to benefit patients and prohibits spread pricing.

There has also been a small but noticeable push for PBM reform at the federal level. In July, United States Representative Buddy Carter (R, GA) introduced the PBM Reform Act of 2025, an act to establish transparency and accountability standards for PBMs involved in Medicaid, Medicare, and group health plans.

As of November 2025, this resolution has not advanced. Given the wave of state-level efforts for PBM reform, inaction at the federal level could spur additional interest during the 2026 state legislative session.

Conclusion

There are advantages to utilizing the services of pharmacy benefit managers. PBMs act as intermediaries for the various stakeholders within the pharmaceutical industry and can alleviate some of the drug cost burden from health insurers and patients. However, despite PBMs’ efforts, the United States has the highest drug prices per capita.⁴³ Though not the only path forward, many states are regulating PBM business practices with the stated goal of ensuring patients are the primary beneficiaries of PBM services. Policymakers are likely to continue exploring options to regulate PBMs for the benefit of patients in their state while attempting to balance the economic tradeoff of such measures.

End Notes

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39. Arkansas HB1150 – TO PROHIBIT A PHARMACY BENEFITS MANAGER FROM OBTAINING CERTAIN PHARMACY PERMITS hearing on House Insurance and Commerce Committee, Arkansas 95th General Assembly (2025)
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