States across the country are ramping up oversight of pharmacy benefit managers (PBMs), investigating pricing practices, challenging vertical integration, and testing restrictions on PBM-owned pharmacies. But SHARx, a procurement management solution for high-cost prescription drugs, wants the conversation to focus on whether reform will materially improve employer costs, patient access, pharmacy choice, or the day-to-day experience of getting medications.
Reform is not the same thing as results,” said Paul Pruitt, Chief Growth Officer of SHARx. “A state can pass a law, open an investigation, or force more reporting, and none of that automatically means an employer is spending less or that a patient is getting medication more easily. If the cost is still there, the friction is still there, and the access problem is still there, then employers should ask what changed.”
Reform Activity Is Accelerating, but Results Are Not Guaranteed
Why SHARx Advocates for Measurable Reform Outcomes
KFF reports that PBM-related legislative efforts have emerged across all 50 states, but the number of bills introduced or enacted does not show whether employers and patients will experience meaningful change. State measures vary widely, may face legal challenges, and do not necessarily apply uniformly to self-funded employer plans. Pruitt says reform should be evaluated by whether it lowers net costs, improves medication access, and gives employers greater control over pharmacy spending.
At the federal level, the Consolidated Appropriations Act of 2026 requires PBMs to pass through 100% of covered rebates, fees, alternative discounts, and other remuneration received from applicable entities. The law includes affiliated group purchasing organizations and rebate aggregators, which must transfer applicable rebates to the PBM within 45 days after the end of each quarter. The PBM generally must then transfer those amounts to the plan within 90 days.
For calendar-year plans, the requirements generally will not apply until Jan. 1, 2029. The law also allows transparent and quantifiable bona fide service fees, making implementation, disclosure, and independent auditing critical. “A pass-through requirement will have limited value if compensation can be relabeled, shifted into another fee category, or obscured through affiliated entities without meaningful employer scrutiny”, says Pruitt.
At a state level, Arkansas took legal steps to become the first state to bar PBMs from owning pharmacies, but the law was blocked in court after CVS Health warned it could close all 23 of its retail pharmacies in the state. Meanwhile, Florida recently subpoenaed CVS Health and Caremark as part of an investigation into alleged anti-competitive pharmacy practices that may have steered patients and disadvantaged independent pharmacies.
The Real Measure Is Outcomes
PBM reform is entering a new phase in which success must be judged by measurable outcomes rather than legislative activity alone. Many reforms demand an increase in reporting requirements or addressing financial relationships within the pharmacy supply chain. While those steps may improve transparency, they do not automatically reduce administrative barriers, reduce costs for patients, or shorten the time it takes patients to begin treatment.
“A lot of these battles focus on where the money goes, not whether the system itself got better,” Pruitt said. “If a reform changes who makes money in the system but does not lower net costs, it is not the kind of win employers are after.”
This distinction is especially relevant for self-funded employers, who ultimately finance prescription benefits while navigating increasingly complex contracts, regulations, and pharmacy networks. Even as reforms advance, employers still need to understand which policies affect their plans, which do not, and whether the federal Employee Retirement Income Security Act of 1974 (ERISA) constraints state authority.
Establishing an Employer Score Card
As PBM scrutiny rises, SHARx says employers and brokers should move past passive reform narratives and ask:
- What exactly did the new law or investigation change?
- Does it affect the employer-PBM relationship or only the pharmacy side of the market?
- Does it alter net-cost exposure or only profit allocation?
- Does it reduce delays, improve contract control, or expand pharmacy choice?
- Does it make the economics easier to evaluate, or just easier to describe?
Pruitt points out that reform debates are dominated by regulators, politicians, pharmacies, and other large players, but its employers who are still the purchasers financing the system.
“Everybody wants to talk about whether PBMs are under pressure,” Pruitt said. “But pressure is not the same as progress. What matters is whether employers have more control, costs are coming down, and patients can get medications more easily. That’s the scorecard that still doesn’t get used enough, and it’s the one that matters.”
