New Bill Makes CMS Enforcer in PBM, Pharmacy Relationship: A Q&A With Jesse Dresser, Esq

Addressing the role of pharmacy benefit managers (PBMs) in the price of prescription drugs has been a major goal for policymakers on both sides of the aisle. The Consolidated Appropriations Act of 2026 addresses some of the concerns that consumers and pharmacies have brought up regarding PBMs, with the law specifically addressing pricing in Medicare Part D. In the second part of an interview with The American Journal of Managed Care^® (AJMC^®), Jesse Dresser, Esq, partner in Frier Levitt’s Life Sciences Department, spoke about what role CMS will now play in addressing increased prices set by PBMs and what the next steps should be in legislation addressing PBMs overall.

Read about how the law will be interpreted by CMS and PBMs in the first part of Dresser’s interview with AJMC.

This transcript has been lightly edited for clarity.

AJMC: What does this mean, going forward, for government involvement in drug pricing, specifically in Medicare?

Dresser: One of the things that the government is going to be involved in is that they’re going to get tremendous amounts of data and reporting from PBMs, from plan sponsors, and from PBM-affiliated pharmacies, where they'll have a much better ability to do a comprehensive analysis of what the economics are in the Part D landscape, something that they really hadn't had the same level of insight on up until this point. But to your point, the bigger transition is going to be CMS' role as standing in the middle of this relationship and being a little bit of an enforcer. One of the things that they are now poised to do is receive complaints from pharmacies. They are poised to have funding to go and investigate complaints and seek to impose penalties and enforcement against PBMs and Part D sponsors when they find that they have violated the rules, when they've not offered reasonable and relevant terms and conditions.

What's interesting is, in addition to creating a mechanism for CMS to be an enforcer, they've also indicated that PBMs are not allowed to retaliate against pharmacies for filing reports with CMS or complaints with CMS, and cannot coerce pharmacies into accepting unreasonable or irrelevant terms and conditions, which is a big protection for network pharmacies. The other thing that CMS did is Congress wanted to make sure that CMS wasn't the only mechanism for there to be relief for negatively affected pharmacies. If you're a pharmacy and you are facing unreasonable terms and conditions, you can complain to CMS, but now the law explicitly states that nothing in the law will diminish or stand in the way of any rights that were available to pharmacies under the law or under contract. We've long taken the position that there are many rights available to pharmacies under their contracts and under the law, particularly the Any Willing Provider law, so what's interesting is even though there is a mechanism to complain through CMS, it’s not the only resolution mechanism available to pharmacy providers.

AJMC: What should pharmacies, PBMs, and other health plans expect to occur? Will this transition be smooth, or do you expect there to be bumps in the road?

Dresser: First off, the law doesn't begin to take effect until 2028, and then it phases in over time, so it will be a little while before we see any real meaningful change. The other thing that I will say is, although the law does provide funding, you have to keep in mind that there has been so much administrative inertia that has been in place for years, for 20 years within the Part D space, where CMS has taken a total hands-off approach. Their doctrine has been, "We don't have jurisdiction; we don't have authority. We're not going to exercise any kind of action." It wasn't even an avenue for pharmacies to submit complaints to CMS. You submit a complaint, and they don't even acknowledge it.

Even though there's going to be funding in this directive, it's like turning around the Titanic. It's going to be a bit of a process to retrain thinking here and retrain the doctrine of what they are empowered to do and expected to do. I don't see this as being something that, on day 1, we're seeing a complaint on CVS, Express Scripts, and Optum's desks. I think it's something that, as it happens, is going to be a very slow-moving process. It's important for pharmacy providers not to expect this to be an overnight fix for PBMs and for Part D plan sponsors. I think there's also going to be a little bit of a learning curve getting used to the new levels of compensation and framework, getting used to the new types of reporting requirements, and making sure that you're kind of trying to stay a step ahead of what the next iterations are of how PBMs are trying to get more percentage-based compensation or money in other parts of the system.

AJMC: How much does this law help with addressing PBMs? Will more laws need to be passed to fully address the challenges that they present?

Dresser: This law, in theory, if it is adhered to, would address a lot of the issues around underwater reimbursement, around unreasonable terms and conditions, around unfair performance metrics, and around unfair auditing practices for pharmacies in Part D networks. It would create a lot of protections there. What the law doesn't do—while it does include some provisions related to the pass-through of rebates related to transparency in the commercial, self-funded, and large group health insurance space—it doesn't pull through these same protections and the same requirements for the relationship between pharmacies and the PBMs in that commercial context. While you're getting a lot more protection in Medicare, you're still really not addressing anything as it relates to pharmacies submitting claims in the commercial context.

I do think this is a great first step. I think it's amazing that Congress has gotten together on a bipartisan measure and said, “We’ve got to do something about these PBMs. We’ve got to do it now.” I've been at this for a long time, going on over 15 years, and we'd spend 30 minutes talking to a lawmaker, we'd spend 30 minutes talking to a judge, and the first question that they would ask is, "So, what's a PMB?” It just wasn't something that people had an understanding of what they were, what they did, or really even just basic recognition of how they operate. Now to get to the point where we're passing bipartisan legislation aimed at reining in some of their abuses, it's fantastic. But I do think that the work needs to continue and needs to expand into the commercial market.