PBM Reforms: What They Mean for Your Prescriptions
Pharmacy Benefit Managers control 80% of the prescription market. Reforms are changing how drugs are priced—and how much you pay.
Prices are estimates only. Verify with provider before booking.•Not medical advice.Emergencies: 911
What Are PBMs & Why Do They Matter?
Pharmacy Benefit Managers (PBMs) like CVS Caremark, Express Scripts, and OptumRx are intermediaries that:
- 1Negotiate drug prices with manufacturers
- 2Manage formularies (approved drug lists)
- 3Process prescription claims
- 4Keep rebates that could lower your costs
The Problem: PBMs control 80% of the market and often use "spread pricing" (charging insurers more than they pay pharmacies) and retain manufacturer rebates instead of passing savings to patients.
2025 State PBM Reforms
24+ states passed 33+ PBM reform bills in 2025—the biggest year for reform yet.
SB 41: Bans spread pricing + requires flat fees (Jan 2026)
SB 3012: PBM licensing + rebate reporting (Jan 2026)
HF 2634: NADAC reimbursement + $10.68 dispensing fee
HB 1234: Bans PBM pharmacy ownership
SB 189: Delinking to flat fees (effective 2027)
HB 1568: Fair network access + floors
SB 127: Transparency requirements + floors
HB 1123: Spread pricing ban in conference
Impact on PatientsPotential Savings: $100-$500/year
Positive Impacts
- Lower out-of-pocket: 100% rebate pass-throughs could cut copays 20-30% ($100-$500/yr)
- Better access: Bans on steering/gag clauses let patients choose pharmacies
- Reduced step therapy delays
- Transparency: Semi-annual reports expose hidden fees
Potential Challenges
- Short-term formulary disruptions possible
- Some rural pharmacies may close during transition
How to Save NOW on Prescriptions
Ask for NADAC Pricing
NADAC (National Average Drug Acquisition Cost) is the true wholesale cost. Many pharmacies will match if you ask.
Compare Cash vs Insurance
With high deductibles, cash-pay is often cheaper. Always ask for both prices.
Use Discount Programs
GoodRx, SingleCare, and Cost Plus Drugs often beat insurance prices.
Request Rebate Pass-Through
Some states require rebates to go to patients. Ask your insurer.
Important Information
- • Price Transparency Only: FairVisitHealth™ helps you find and compare healthcare prices. We are NOT a medical provider.
- • No Medical Advice: Information shown is for comparison only. Always consult a licensed healthcare provider for medical decisions.
- • Verify Prices: Always confirm pricing directly with providers before scheduling. Prices may vary based on your specific needs.
- • No Patient Data: We do NOT collect, store, or transmit protected health information (PHI).
- • No Audio/Calls: This app does NOT request microphone or phone permissions. The camera is used only if you choose to photograph a bill for analysis. All telehealth via external platforms.
- • Emergency: For medical emergencies, call 911 immediately.