2026 PBM Industry Outlook: Key Legislative Updates and What Plan Sponsors Should Prepare For

As we close the chapter on month one of 2026, we’re seeing pharmacy benefit regulation, drug pricing oversight, and PBM reform accelerate at a pace the industry has not seen in years. In our State of the PBM Industry in 2025 blog, we outlined major forces reshaping the market—specialty drug inflation, supply chain volatility, transparency mandates, and the shift toward consumer-grade technology. Now, it's time to look ahead with our 2026 PBM Industry Outlook. This will provide a concise, actionable view of what’s changing, what may return in upcoming legislative sessions, and what employers, TPAs, brokers, and health plans should prioritize now.

1. National and State PBM Regulatory Activity to Watch in 2026

Federal PBM and Drug-Pricing Reform

Congress and federal agencies continue advancing legislation targeting PBM pricing practices, rebate flows, and pharmacy steering. New proposals emphasize transparency, reporting requirements, and tighter oversight of intermediaries.

These changes reinforce a broader trend we outlined in our 2025 PBM report: organizations increasingly expect PBM partners to operate with clear alignment to plan-sponsor goals rather than opaque vendor incentives.

Medicare Part D and Benefit Design Modernization

CMS’s 2026 Final Rule introduces updates to drug price negotiation, member cost sharing limits, and benefit structure. These changes increase the importance of real-time pricing tools and member navigation support, capabilities core to Rexi™ and myRescription™.

State Level PBM Legislation

States remain active drivers of PBM reform. In 2025, more than half of states advanced bills involving:

• Rebate passthrough requirements

• Pharmacy reimbursement floors

• Spread pricing restrictions

• Transparency and reporting obligations

• Pharmacist scope-of-practice expansions

States such as Texas, Colorado, Florida, Indiana, and California are expected to lead additional regulatory efforts in 2026. Multi-state employers and health plans must prepare for differing rules across service areas.

2. Legislative Proposals Likely to Reappear in 2026

Enhanced PBM Transparency Requirements

Bills requiring detailed rebate and pricing disclosures, pharmacy network reporting, and real-time cost data may return with stronger support. These proposals reflect policymakers’ growing focus on reducing variability in drug pricing.

Digital Prescribing Information Modernization

Efforts to shift prescribing information from paper to digital formats—improving accuracy, speed, and workflow consistency—are expected to resurface. This trend aligns with the broader move toward digital pharmacy infrastructure.

Supply Chain and Pricing Stability Measures

Legislators may revisit policies linked to drug importation pilots, tariff adjustments, and incentives for domestic manufacturing. These proposals could materially affect net cost projections, particularly for specialty and infused therapies.

3. Market Forces Accelerating Into 2026

Specialty Drug Spend Growth

Specialty therapies continue to account for a disproportionate share of total drug spend. Employers and plans should update multi-year modeling, review stop loss strategies, and confirm whether their PBM or PBM alternative can support emerging high-cost therapies.

Consumer-Grade, Real-Time Member Tools

Real-time price transparency, benefit modeling, proactive notifications, and out-of-pocket forecasting are becoming baseline expectations. The operational environment is shifting from static formularies to dynamic, member-centric pricing tools.

Shifting PBM Relationship Dynamics

As we outlined in our 2025 PBM industry analysis, employers, brokers, and TPAs increasingly view PBMs as strategic partners, not commoditized vendors. Value now derives from transparency, alignment, and measurable plan outcomes.

4. What Plan Sponsors Should Prioritize for 2026

1. Conduct comprehensive contract and pricing audits Review rebate arrangements, spread pricing exposure, network design, and specialty drug terms.

2. Prepare for state-by-state compliance requirements Create a monitoring framework to track legislation across states where members reside or receive care.

3. Strengthen specialty cost projections Model multi-year high-cost therapy scenarios and ensure financial protection frameworks are aligned.

4. Accelerate adoption of member-centric technology Support real-time pricing, benefit navigation, and proactive cost notifications.

5. Align partner incentives Ensure PBMs, TPAs, brokers, and consultants are evaluated based on plan-sponsor outcomes rather than transactional metrics.

Check out our blog for what to look for in a PBM partner.

FAQ: 2026 PBM and Drug Pricing Changes

How will PBM reform affect employers and health plans in 2026?

You should expect increased reporting requirements, more transparent pricing structures, and shifts away from spread pricing. Plans operating in multiple states will see varied compliance obligations.

What should TPAs and brokers do now to prepare?

Review PBM contracts, update specialty forecasting, and confirm that member facing technologies support real-time pricing and navigation.

Which states are most active in PBM legislation?

States such as Texas, Florida, Colorado, Indiana, Tennessee, and California continue to drive aggressive PBM reform efforts, with more expected in the 2026 sessions.

How will Medicare Part D changes impact plan design?

Benefit structures may shift as price negotiation and cost sharing caps evolve. Plans should prepare to adjust communication, modeling, and technology integrations.

Closing Outlook

Many of the forces we outlined in our State of the PBM Industry in 2025 report—specialty-drug inflation, transparency mandates, digital transformation, and supply chain volatility—are now shaping the 2026 landscape. Organizations that modernize their benefit strategies, align incentives across partners, and adopt real-time pricing technologies will be best positioned for stability, compliance, and member value.