PBM reform is no longer a hypothetical. On February 3, 2026, the Consolidated Appropriations Act (HR 7148) was signed into law with the most significant PBM transparency provisions Congress has ever passed. The law includes rebate pass-through requirements, flat-fee service mandates, standardized reporting obligations, and expanded federal oversight across Medicare Part D and commercial markets. Most provisions take effect for plan years beginning on or after August 3, 2028 — or January 1, 2029 for calendar-year plans. The law is settled. You have roughly two years to position for it.
One notable provision: Section 6223 (“Assuring Pharmacy Access and Choice for Medicare Beneficiaries”) establishes strengthened “any willing pharmacy” requirements for Medicare Part D networks. Contract terms offered to pharmacies must be “reasonable and relevant” per standards the HHS Secretary will establish by April 2028, with requirements applying to plan years beginning January 1, 2029.
One notable omission: HR 3164, the Ensuring Community Access to Pharmacist Services Act, was not included. That bill would have expanded Medicare Part B to cover pharmacist-administered testing and prescribing for conditions like flu, RSV, strep, and COVID — a provider-status expansion with direct implications for FQHC pharmacy operations. It advanced through the Ways and Means Committee but did not make the final appropriations package. For FQHCs that have invested in clinical pharmacy services, this exclusion matters.
Spread Pricing Transparency
The new law requires PBMs to pass through 100 percent of rebates to plan sponsors rather than retaining a portion. In the previous model, a PBM might reimburse your pharmacy $8 for a generic drug while charging the plan sponsor $25, pocketing the $17 difference. Under the new transparency requirements, that spread becomes visible and must be disclosed.
For FQHC pharmacies, this could improve reimbursement on generic drugs where spread pricing currently suppresses what you are paid. But it could also reduce reimbursement on brand drugs where PBMs currently overpay pharmacies to offset the spread they capture elsewhere. The net impact depends on your formulary mix.
DIR Fee Reform
Direct and indirect remuneration fees — the retroactive clawbacks PBMs impose on pharmacies after the point of sale — are directly addressed. The law moves toward requiring that price concessions be applied at the point of sale so pharmacies know their actual reimbursement when they fill the prescription.
For 340B covered entities, this is significant. Currently, a prescription might show a positive margin at the point of sale, but after DIR fees are assessed months later, the actual reimbursement falls below acquisition cost. This makes 340B savings calculations unreliable and creates cash flow uncertainty. Point-of-sale application would give you accurate margin data in real time.
Delinking and the 340B Implications
Some provisions and standalone bills still in early stages — including the Break Up Big Medicine Act (S. 3822, introduced by Senators Warren and Hawley in February and referred to the Senate Judiciary Committee) — target the structural relationship between PBM compensation and drug list prices. If PBMs are no longer incentivized to prefer high-list-price drugs, formulary composition could shift toward lower-cost alternatives. For 340B programs, this matters because 340B savings are calculated as the spread between the ceiling price and the reimbursement amount. If reimbursement rates shift downward alongside list prices, the 340B spread could narrow.
This structural shift will take years to play out. But the directional risk is worth modeling now.
What to Do Before 2028
The timeline is known: most provisions phase in for plan years beginning August 3, 2028 or January 1, 2029. That gives you roughly two years. Here is how to use them.
First, understand your current PBM contract terms in detail — what you are being reimbursed, what DIR fees you are paying, and how spread pricing affects your margins. Most pharmacy directors cannot answer these questions precisely because the PBM contracts are managed at the organizational level and the pharmacy never sees the terms. Under the new law, you will have a right to that information. Start requesting it now.
Second, model the impact of pass-through pricing on your top 50 drugs by volume. If spread pricing disappears, which drugs get better reimbursement and which get worse? That analysis takes a few hours and gives you a concrete number to plan around.
Third, watch for HHS rulemaking on the Section 6223 pharmacy network provisions. The statute directs HHS to define “reasonable and relevant” contract terms for network participation. Those definitions will determine whether the provision meaningfully opens PBM networks or simply codifies existing barriers under new language.
Fourth, engage with your state pharmacy association on HR 3164 or its successor. Pharmacist provider status under Medicare Part B remains the largest unfinished piece of pharmacy policy reform. FQHCs have a compelling story to tell about clinical pharmacy services. Make sure it is heard in the next legislative cycle.
References
- Consolidated Appropriations Act, 2026 (HR 7148). Signed Feb 3, 2026. congress.gov
- Mintz. “Congress Passes Landmark PBM Reform in 2026 Spending Bill.” Feb 6, 2026.
- Pharmacy Times. “PBM Reform Within 2026 Appropriations Bill Signed Into Law.” Feb 2026.
- Congress.gov. S.3345 — PBM Price Transparency and Accountability Act.
- Congress.gov. HR 3164 — Ensuring Community Access to Pharmacist Services Act.
- Duane Morris. “Congressional PBM Reform: New Contract Standards.” Jan 2026.