A New Era for PBMs
Key Medicare Part D Reforms in the 2026 Consolidated Appropriations Act
The Consolidated Appropriations Act, 2026 (H.R.7148), signed into law on February 3, 2026, introduces significant reforms to pharmacy benefit manager (PBM) practices within the Medicare Part D program. This legislation is designed to enhance transparency and redefine PBM compensation models, marking a shift in how PBMs operate within the Medicare Part D landscape. Here are key PBM reforms introduced under H.R.7148 to watch closely.
Key PBM Reforms under H.R.7148 that Impact Medicare Part D
- Pass-Through of Manufacturer Rebates. PBMs must fully pass through all manufacturer rebates, discounts, and other price concessions directly to Medicare Part D plan sponsors. This ensures that cost savings benefit the plan sponsors, as PBMs will no longer be allowed to retain or profit from these concessions.
- Prohibition of Certain Revenues. PBMs are prohibited from earning revenues tied to drug utilization associated with covered Part D drugs. PBM revenue must meet the definition of Bona Fide Service Fees (BFSFs). These fees must reflect fair market value, exclude indirect remuneration (e.g., rebates), and be independent of drug pricing or utilization metrics.
- Enhanced Oversight. The Department of Health and Human Services (HHS) and its Office of Inspector General will be granted expanded oversight authority. This includes the ability to scrutinize PBM arrangements with Part D sponsors and manufacturers to ensure fees comply with fair market value and other provisions.
- Transparency Requirements. PBMs must report detailed data on rebates, pricing, and fees to HHS. Additionally, Part D sponsors will receive data on the contractual arrangements between PBMs and manufacturers and will have the right to audit PBM activities annually.
How Myers and Stauffer Can Help
With more than 20 years of experience auditing Medicare Part D plans and their PBMs, Myers and Stauffer has developed deep expertise in these areas.
- Contract Analysis. We have extensive experience analyzing PBM contracts, including agreements between PBMs and rebate aggregators, to identify terms that may affect federal reporting requirements and PBM revenue streams.
- DIR Expertise. Our team routinely uncovers issues related to direct and indirect remuneration (DIR) calculations and reporting, such as unreported DIR retained by Part D plans, PBMs, or downstream rebate aggregators.
- BFSF Analysis. We have significant expertise in analyzing BFSFs, ensuring that all fees are reported in accordance with fair market value requirements and conform with federal and contractual standards.
Myers and Stauffer is well positioned to support governmental oversight activities to ensure timely compliance with the federal PBM reform requirements.
For More Information
Keith Sorensen, CPA, CFE
Member
Andy Ranck, CPA
Member
