Plan sponsors know all too well that the rules governing how they structure and pay for pharmacy benefits are rapidly evolving.
From federal laws impacting reporting requirements, to executive branch policies impacting drug costs, to more than 1,300 pharmacy-related bills in state legislatures, the breadth of potential changes is vast.
In this report, we’ll highlight a few key trends most likely to have a meaningful impact on the cost and administration of the pharmacy benefit.
Bills at the federal level impacting pharmacy benefits have existed for several years. However, things changed in earnest in February when the Consolidated Appropriations Act of 2026 was signed into law. The law consisted of provisions aimed at a variety of government functions from national defense to education but also contained new requirements related to pharmacy benefits.
These regulations include enhanced reporting obligations for pharmacy care services providers as well as provisions mandating 100% pass-through of rebates. Notably, these requirements come in the wake of longstanding initiatives by Optum Rx® to offer plan sponsors greater choice and transparency, such as Cost Made Clear pricing models, which already feature 100% pass-through options.
As we noted in a previous insights brief, the Centers for Medicare & Medicaid Services (CMS) is now required to negotiate directly with drug manufacturers to reduce the price of popular drugs. Known as Maximum Fair Prices (MFPs), these annual negotiations were mandated to target select high-expenditure drugs for price cuts in Medicare Part D. These negotiated prices are now being reflected in lower list prices, accelerating an existing trend away from rebates and altering cash flows and formulary decisions for plan sponsors.
More recently, the Trump administration has announced several actions intended to lower prescription drug prices for consumers. These include agreements with 17 pharmaceutical companies to link prescription drug prices for Americans with those paid by other developed nations, also known as most-favored-nation (MFN) prices.
The Trump administration also announced several policies targeting the cost of GLP-1 drugs for weight loss. These included instructing CMS to reinterpret an existing statutory exclusion of anti-obesity agents to allow coverage of GLP-1s prescribed for weight loss under Medicare Part D, as well as a $150 per month direct-to-consumer offering through TrumpRx.
However, in April 2026 the administration announced that it is indefinitely delaying implementation of the Medicare pilot program covering GLP-1s due to hesitancy from private Medicare insurers. A separate Medicaid pilot for GLP-1 coverage conducted by CMS is still ongoing, and states have until July 31 to decide to participate.
The 2026 legislative cycle has seen more than 1,300 pharmacy‑related bills introduced at state legislatures, including approximately 650 measures carried over from 2025. Since many states operate on short timelines of 30 to 60 days, legislation can advance quickly and with limited warning.
While a growing trend at the state level is the use of expansive bills that bundle multiple pharmacy benefit management (PBM) and pharmacy provisions into a single proposal, a few common policy themes account for the bulk of pharmacy-related legislation proposed in 2026. These include:
ERISA preemption. These laws would allow state regulators to enforce benefit administration requirements on ERISA plans, challenging long-standing federal preemption principles and potentially fragmenting plan administration across state lines.
In addition, states are taking aim at restricting certain ownership structures in pharmacy care services. Bills that prohibit PBMs from owning or operating pharmacies have become more popular in states this year. If enacted, these measures would eliminate access to integrated pharmacy options, such as home delivery, specialty pharmacy, infusion services and behavioral health pharmacies for residents of affected states, potentially reducing convenience and increasing costs for employers and members.
Collectively, these state and federal initiatives signal potential upheaval in pharmacy benefit design, drug pricing and integrated care models. Legislative outcomes can have significant cost impacts on plan sponsors, reducing choice and flexibility in how they manage prescription drug benefits for their members.
That is why proactive monitoring and timely advocacy will remain critical tools for navigating this regulatory environment. Optum Rx meets with policymakers, legislators and regulators to educate them about the potential implications these laws can have.
Against this rapidly evolving backdrop, Optum Rx is committed to helping plan sponsors as your strategic advisor. The Optum Rx Policy team hosts regular webinars to help keep you informed of this increasingly complex and active regulatory environment. These bimonthly sessions dive deep into the latest proposed legislation and rulemaking you need to be aware of.
Register for future webinar sessions
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