Congress Eyes PBM Reform: Can Bipartisan Action Finally Fix America’s Drug Pricing System?

Forbes – Online Article – November 18, 2025 – PBM reform 2025

After years of gridlock in Washington, bipartisan momentum is building around one critical issue — reforming Pharmacy Benefit Managers (PBMs). Lawmakers from both sides of the aisle agree that the lack of transparency and accountability in how PBMs operate is driving up prescription drug costs for patients, employers, and taxpayers alike.

The Problem: Profits Over Patients

PBMs were originally designed to negotiate lower drug prices and manage formularies — the lists of medications that insurers cover. But over time, their role has evolved into something far less patient-friendly.

While PBMs claim to save money, their opaque pricing structures and hidden rebates often do the opposite. Discounts negotiated with drug manufacturers have grown faster than list prices, meaning insurers and PBMs pocket savings while patients pay inflated out-of-pocket costs based on higher list prices.

This system rewards PBMs and insurers for favoring drugs with higher list prices and deeper rebates, even when cheaper alternatives exist. The result? Patients shoulder higher copays, small pharmacies face unsustainable reimbursement rates, and the overall healthcare system absorbs billions in unnecessary costs.

The FTC and Congress Step In

The Federal Trade Commission (FTC) has confirmed that PBMs are gaming the system and inflating drug costs. In response, Congress is now considering comprehensive PBM reform to improve transparency, stop rebate manipulation, and ensure patients benefit directly from negotiated discounts.

Yet PBMs continue to evolve their business models to stay one step ahead. One of their newest tactics involves using Group Purchasing Organizations (GPOs) — often located overseas — to conceal profits and reduce oversight.

These GPOs operate similarly to PBMs, pooling purchasing power to negotiate prices. However, by routing deals through foreign GPOs, PBMs can hide revenue streams and avoid U.S. transparency regulations.

Follow the Money: GPO Fees on the Rise

In 2012, GPO and PBM fees accounted for just 5% of PBM profits. Today, those fees exceed 20% of profits, according to industry analyses. Despite criticism of their rebate practices, PBMs have simply shifted their profit model, diverting as much as 50 cents of every dollar spent on prescription drugs to middlemen and administrative fees.

The House Oversight and Government Reform Committee recently announced an investigation into how PBMs use GPOs to evade scrutiny and stash profits overseas. Lawmakers want to understand how the “big three” PBMs — CVS Caremark, OptumRx, and Express Scripts — are exploiting these structures to the detriment of American consumers and independent pharmacies.

Why Reform Matters

Despite declining net drug prices, out-of-pocket costs for patients continue to climb. That mismatch shows exactly why PBM reform is overdue. Meaningful legislation could:

• Ensure patients benefit from negotiated discounts

• Require full transparency in PBM and GPO contracts

• Prevent self-dealing by PBMs that own their own pharmacies and insurance companies

• Restore fair reimbursement for independent pharmacies that serve their communities

The stakes are high — and for millions of patients, reform could mean the difference between affordable access and skipped prescriptions.

RescueMeds’ Perspective

At RescueMeds, we see firsthand how PBM practices impact patient care and pharmacy sustainability. We support efforts that increase transparency, reward ethical pricing, and protect patient access to affordable medications.

Pharmacy reform isn’t just about lowering costs — it’s about restoring fairness and trust in a system that should put patients, not profits, first.