A growing wave of reforms targeting pharmacy benefit managers (PBMs) is beginning to reshape the economics of prescription drug access. From congressional proposals aimed at PBM business models to state-level efforts to increase oversight, policymakers are challenging long-standing industry practices.
For pharmaceutical manufacturers, the implications are immediate and extend well beyond contracting. The traditional rebate-driven market is giving way to a model in which net price, clinical value, and total cost of care are directly evaluated by the economic buyer.
How drug access decisions are changing in a post-PBM reform market
The widespread use of rebates has enabled PBMs to play a significant role in determining formulary access. But under emerging reform models, employers, health plans, and other financially accountable stakeholders are gaining greater influence over coverage decisions and evaluating therapies through a broader economic lens.
Three structural changes are driving this shift:
1. Rebates and price concessions are increasingly being passed through to plans, reducing the economic leverage historically retained by PBMs.
2. PBM compensation is being delinked from drug price and volume, weakening incentives to favor higher-priced, higher-rebate products.
3. Enhanced transparency requirements enable plan sponsors to directly evaluate therapies based on net cost, alongside clinical and operational considerations.
As transparency increases, manufacturers should expect heightened scrutiny of pricing structures and gross-to-net economics. Products that have historically relied on rebate-driven positioning may find it increasingly difficult to maintain access if they cannot compete on net price or demonstrate measurable value.
The pace at which market segments respond and adapt to the reforms will vary. Large, self-insured employers are expected to move fastest, driven by demands for transparency and a growing focus on total healthcare spending. Fully insured commercial plans will likely evolve more gradually as existing PBM relationships and contracting structures remain in place. Medicare Part D is also undergoing a transformation through the Inflation Reduction Act reforms and changing plan liability dynamics.
This means drugmakers need to develop more targeted access strategies. Organizations should prioritize segments where the shift to net-price and value-based competition is most immediate.
Winners will quickly emerge under a more transparent market
Greater transparency is also likely to spure more competition, especially in therapeutic areas with multiple treatment alternatives. Manufacturers with highly differentiated products supported by strong economic evidence may gain an advantage. Products that depend heavily on rebates and lack meaningful differentiation could face increased price compression, formulary exclusion, and share erosion.
This creates a need for manufacturers to identify which assets remain competitive and which may require repositioning, pricing redesign, or enhanced value evidence.
The companies aiming to position themselves to succeed in this near environment should take quick action, including:
- Stress-testing portfolio economics against a future where net price transparency becomes the norm.
- Strengthening decision-grade value evidence by quantifying total cost-of-care impact and real-world outcomes.
- Expanding stakeholder engagement beyond PBMs to include employers, plan sponsors, consultants, and other emerging decision-makers.
Manufacturers that proactively adapt their pricing, evidence generation, and market access strategies will be better positioned to compete as PBM reforms reshape the market.
