Patients Before Monopolies Act

By: David Ostrowsky

Already, 2026 has seen a spate of reforms passed for pharmacy benefit managers (PBMs), known for their role in coordinating drug manufacturers, pharmacies and insurance companies, and who preside over Rx benefits, negotiate prices of pharmaceuticals, process claims, and monitor lists of covered medications. The sea change began last winter, when Congress passed monumental legislation that overhauled the industry. Among other measures, there were new transparency reporting requirements enacted; the banning of the practice known as “spread pricing” in commercial insurance plans, whereby some PBMs allegedly charge a plan more for a prescription than they reimburse the pharmacy and retain the price differential; and the delinking of PBMs’ compensation to the list price of the medication they select for coverage.

Meanwhile, even more PBM reforms may be forthcoming. This past May, a bipartisan group of lawmakers in both chambers of Congress reintroduced a bill designed to prevent healthcare companies that own PBMs from also owning retail pharmacies. Currently, the most prominent healthcare organizations each own a PBM—which pay for pharmacy services—along with the pharmacy chains that provide those services. There is a belief among some industry stakeholders that this dynamic may lead to a conflict of interest, and ultimately, higher drug prices for patients, fewer independent pharmacies, and greater profits for the corporate healthcare giants.

Apparently, that tenet is also shared by some politicians.

After U.S. Senators Josh Hawley (R-Mo.) and Elizabeth Warren (D-Mass.) introduced the Break Up Big Medicine Act in February to address widespread healthcare consolidation, Congresswoman Diana Harshbarger (R-TN) and Congressman Jake Auchincloss (D-MA) reintroduced the Patients Before Monopolies (PBM) Act, first introduced in December 2024, in another attempt to rein in prescription drug prices.

In the official press release issued on May 13, Harshbarger was quoted as saying, “When the same corporate giant that sets reimbursement rates also owns the pharmacy collecting them, that’s not a free market…” “… Congress has a duty to restore fair competition. The Patients Before Monopolies Act ends this blatant conflict of interest once and for all.”

Should the Patients Before Monopolies Act pass, such vertically integrated companies would have one year to sell their respective retail pharmacies, including specialty units, which are a prime source of significant revenue streams in dispensing and managing expensive and highly complex medications for healthcare consumers suffering from severe and chronic conditions. (Some industry experts believe that PBMs have been able to generate profits by steering consumers towards their own vertically integrated mail-order and specialty pharmacies.) A parent company that doesn’t divest its pharmacy business within one year of the bill’s enactment could be subject to disgorgement of profits and forced sales of assets. Additionally, the PBM Act, which has secured an endorsement from the National Community Pharmacists Association (NCPA), would allow private parties, such as independent pharmacists, to bring lawsuits against those who are non-compliant; direct the FTC to disseminate any funds raised by penalties to harmed communities, including patients overcharged at vertically integrated pharmacies; and permit the FTC and DOJ to obstruct further actions that would reproduce anticompetitive conditions targeted by the bill.

Understandably, there has been strong pushback from the PBM community as the antitrust legislation projects to have severe repercussions on their industry. Greg Lopes, a spokesperson for the Pharmaceutical Care Management Association, a group representing pharmacy benefit managers, told USA Today in May that the legislation would make it more challenging for patients navigating an already complex system.

“One of the things American patients and families most dislike about our health care system is how fragmented and complex it is, and this legislation would only make that problem far worse – sending patients into a deeper maze of discontinuous care,” Lopes offered.

While at the federal level, the fate of the Patients Before Monopolies Act remains to be seen, at the state level, there has been considerable momentum for enacting restrictions on perceived vertical integration in the PBM industry. On May 22, Tennessee Governor Bill Lee signed the Fair Rx Act into law, effectively prohibiting companies from concurrently owning pharmacies and PBMs in the state. The Fair Rx Act is scheduled to go into law on July 1, 2028. Meanwhile, in 2025, Arkansas tried to become the first state to pass a law that would have hindered PBMs from owning and operating pharmacies in the state, however a U.S. district judge did grant a preliminary injunction, temporarily halting the law’s enforcement.