Patients Before Monopolies Act: Proposed Breakup of PBM-Owned Pharmacies Could Reshape Drug Pricing Landscape
Key Insights
The bipartisan Patients Before Monopolies Act would force healthcare conglomerates like Cigna, CVS Health, and UnitedHealth (search) to divest their retail and specialty pharmacies within one year.
Specialty pharmacy has grown to 35% of PBM revenues by 2023, making mandated divestiture a far greater threat to industry profitability than existing federal reforms.
Current reforms under the Consolidated Appropriations Act require 100% rebate pass-through and delink PBM compensation from drug list prices, but won't be fully implemented until 2029.
A bipartisan group of legislators last month reintroduced the Patients Before Monopolies Act, a bill that would prohibit healthcare companies that own pharmacy benefit managers from also owning retail pharmacies. If passed, vertically integrated conglomerates — including Cigna, CVS Health, and UnitedHealth (search), which respectively control Express Scripts (search), CVS Caremark (search), and OptumRx (search) — would have one year to sell their pharmacy operations. This proposed legislation represents what analysts describe as a far greater threat to health insurance industry profitability than the suite of PBM reforms enacted earlier this year.
The bill targets the structural foundation of an industry that has undergone a dramatic revenue transformation over the past decade. While rebates and related cash streams comprised nearly 50% of PBM revenue in 2012, that figure had dropped to under 15% by 2023. Over the same period, specialty pharmacy revenue surged from 16% to 35% of the PBM revenue mix, making it the single largest profit engine for these intermediaries.
The Limits of Current Reforms
The Consolidated Appropriations Act (CAA), signed into law on February 3 as part of a broader federal spending package, introduced several measures aimed at curbing PBM practices. Under the law, PBMs in Medicare Part D will transition from percentage-based compensation tied to a drug's sticker price to flat-dollar service fees beginning in 2028. The legislation also mandates 100% pass-through of manufacturer rebates, fees, alternative discounts, and other remuneration to plan sponsors in both commercial and Medicare markets.
"The new provisions aim to decouple PBM compensation in Medicare Part D from the list price of medications and from manufacturer rebate arrangements," said Sumedh Mankar, DO, MPH, FCAPM, a triple board-certified osteopathic physician. "PBMs will no longer earn greater compensation simply because a drug has a higher price or larger rebate."
However, the CAA's provisions will not be fully implemented until 2029. A proposed Department of Labor rule would serve as an interim bridge, requiring self-funded plan sponsors to disclose PBM compensation arrangements as early as this year. Separately, an FTC settlement stipulates that starting next year, PBMs must offer plan sponsors a standard option that passes manufacturer rebates and discounts directly to patients at the pharmacy counter, along with standard offerings that eliminate spread pricing — though employer plan sponsors may opt out of these arrangements.
Why Structural Separation Matters
Despite these reforms, experts caution that PBMs have historically demonstrated an ability to offset diminished revenue sources. "While the regulations on tap will further disrupt the rebate system, they're following an already existing process rather than instigating a transformation," the analysis notes. Because the vertically integrated conglomerates remain intact under current law, PBMs can continue diversifying their revenue streams.
The Patients Before Monopolies Act directly confronts this by targeting retail and specialty pharmacies. By controlling the pharmacy that dispenses expensive specialty medications — such as biologic oncology drugs — a vertically integrated PBM can inflate dispensing margins, force patients to use restrictive provider networks, and discriminate against independent pharmacies by under-reimbursing them.
Madelaine Feldman, MD, FACR, vice president of advocacy and government affairs for the Coalition of State Rheumatology Organizations, described the current landscape in stark terms: "For too long, PBMs have operated through anticompetitive, deceptive, opaque and, at times, fraudulent practices that drive up drug costs while harming patients, providers, employers, unions and pharmacists alike."
State-Level Momentum and Legal Challenges
Several states have already moved to address PBM-pharmacy integration. On May 22, Tennessee Governor Bill Lee signed a PBM reform bill that prevents PBMs from holding pharmacy licenses in the state and requires divested pharmacy ownership by July 1, 2028. The law also mandates that a portion of rebates be passed to patients and plan sponsors, and prohibits PBMs from charging patients or sponsors more for a medication than the PBM initially paid. CVS filed a lawsuit against the Tennessee law on May 26.
"If the divestiture holds up in court for all plans, including the ERISA plans, this will be a huge win affecting employers, patients and providers," Feldman said. She specifically cited the potential to reduce costs for generic small-molecule drugs, referencing "the debacle of what happened with the high prices of imatinib (Gleevec, Novartis) when it went generic."
The Fiduciary Question
Beyond structural separation, additional legislative efforts aim to strengthen PBM accountability. The bipartisan PBM Fiduciary Accountability, Integrity, and Reform (FAIR) Act, introduced in Congress in late 2025, would amend ERISA to classify PBMs as fiduciaries, legally requiring them to act in the best interest of plans and beneficiaries. Under current CAA provisions, PBMs are designated as covered service providers, which strengthens fiduciary oversight of compensation but stops short of declaring PBMs full fiduciaries.
A spokesperson for the American Medical Association characterized the CAA reforms as "the most significant federal changes to PBM practices in decades," while acknowledging that the organization "will continue to monitor areas not addressed in the Continuing Resolution but remain persistent challenges for patients and physicians such as prior authorization and utilization management reforms, as well as concerns related to market concentration and vertical integration."
Implications for Patients and Providers
For patients, the hope is that transparency around price concessions will translate to lower out-of-pocket costs, though Feldman noted there is "no mandate to make co-insurance based on post price concession." For providers, removing the incentive for PBMs to favor higher-priced medications could lead to formulary construction "less geared toward profit — but, somehow, profits always seem to top priority for PBMs."
Mankar emphasized that primary care physicians can play an important role through advocacy at local, state, and national levels, while also remaining "attentive to formulary design and to prescribe lower-cost, therapeutically equivalent medications whenever possible."
The federal actions collectively reflect a clear shift toward greater scrutiny of PBMs and the opacity of the system in which they operate. Yet as the analysis concludes, while the PBM reforms passed earlier this year will spur further changes in business practices, it is the antitrust legislation — the Patients Before Monopolies Act — that could have the most profound impact on the prescription drug supply chain.