Specialty Pharmacy Contracts Shift Under PBM, CMS Rules: Jesse Dresser

Federal legislation, regulatory action, and legal settlements are converging to change how specialty pharmacies contract with pharmacy benefit managers (PBMs) and how they are paid for high-cost therapies.

In a session at the National Association of Specialty Pharmacy (NASP) inSPire2026 meeting, Jesse Dresser, partner at Frier Levitt, outlined the developments most likely to affect specialty and health system pharmacies. These include PBM provisions in the Consolidated Appropriations Act, recent Federal Trade Commission (FTC) settlements with Express Scripts and CVS Caremark, and shifts in the 340B Drug Pricing Program.

Central to the discussion was a requirement that PBM terms and conditions offered to pharmacies be “reasonable and relevant.” Federal law has long included an any-willing-provider concept, but Dresser noted it had rarely been applied to PBMs, much less enforced against them. The Consolidated Appropriations Act changes that, giving CMS explicit authority to define what “reasonable and relevant” means in practice and to enforce the standard through a complaint process.

To carry out that mandate, CMS released a Request for Information (RFI) during the NASP meeting. The RFI asks pharmacies and other stakeholders for input on core contract elements, including reimbursement rates and dispensing fees. The resulting standards are expected to govern Medicare Part D pharmacy contracting beginning in 2027. That makes pharmacy comments submitted now especially consequential.

Meanwhile, the FTC settlements are speeding a shift toward cost-plus contracting. Under these models, pharmacies are reimbursed based on their actual acquisition cost plus a fee or markup, rather than a discount off a benchmark price. Dresser cautioned that many emerging cost-plus contracts appear designed for retail pharmacies. They may not include dispensing fees or margins adequate to cover the clinical and operational work that specialty pharmacy requires.

Dresser urged specialty pharmacies to engage directly with CMS and the FTC, respond to the RFI, and scrutinize new cost-plus arrangements before signing. The goal, he said, is to make sure reimbursement reflects the true cost of dispensing complex, high-touch therapies.