PBM Reforms Signed Into Law, Reshaping Medicare Part D Drug Pricing Transparency
Key Takeaways
- Medicare Part D PBM compensation shifts to flat administrative fees, aiming to reduce incentives that favor higher-list-price products driven by rebate maximization.
- Mandatory 100% pass-through of rebates, fees, and remuneration to payers is coupled with CMS monetary penalties to enforce compliance.
- CMS must standardize and police “reasonable and relevant” PBM contract terms, including transparency around reimbursement and dispensing fees and an appeals pathway for pharmacies.
- Semiannual reporting expands visibility into gross-to-net dynamics, spread pricing, formulary placement rationale, and incentives steering beneficiaries toward PBM-affiliated pharmacies.
- Major PBMs are already migrating toward rebate pass-through models, raising concern that revenue recapture via administrative fees could limit downstream patient savings.
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