State and federal policymakers are increasingly focused on strengthening oversight of pharmacy benefit managers (PBMs) and their relationships with manufacturers, health plans, and pharmacies. While approaches vary, recent activity signals heightened scrutiny of PBM-pharmacy ownership and its potential implications across the healthcare system.

In April 2025, AR became the first state to ban PBM-owned pharmacies. Working under its authority to regulate pharmacies, the law will prohibit a PBM from operating a pharmacy within the state, or from acquiring a direct or indirect ownership interest in a permitted pharmacy. However, the law is currently under review after being blocked by a federal judge, highlighting both the innovative and contentious nature of PBM reform legislation. Since the passage of AR Act 624, several states have followed suit and advanced similar legislation:

• Indiana: SB140 was passed, establishing guardrails for PBM-pharmacy contracts; an earlier version of the bill would have prohibited PBM ownership of pharmacies.
• Louisiana: SR209 passed, directing the LA Department of Health to study the impact of prohibition of PBM pharmacy ownership and submit a report to the legislature.
• New York: A6546 was introduced and, if passed, would prohibit PBMs from directly or indirectly owning, operating, or controlling a pharmacy.
• Texas: HB 5457 did not pass out of committee, but would have prohibited PBMs from directly, or indirectly through an intermediary, controlling a pharmacy.
• Vermont: H156 did not pass out of committee but would have prohibited a PBM from owning or operating a pharmacy.

At the federal level Senators Elizabeth Warren (D-MA) and Josh Hawley (R-MO) introduced the Patients Before Monopolies Act in 2024 that would prohibit PBM or insurer ownership of a pharmacy; the bill was accompanied by a House version introduced by Representatives Diana Harshbarger (R-TN-1) and Jake Auchincloss (D-MA-4). These bills would require PBMs to divest from pharmacy ownership within three years and would have granted additional authority to the Federal Trade Commission (FTC), Department of Health and Human Services, and the Department of Justice for oversight and enforcement of PBM relationships.

Meanwhile, President Trump has renewed his interest in the role of intermediaries, pledging to “reevaluate the role of middlemen” in drug distribution channels. In a public listening session, FTC Chair Andrew Ferguson also pledged to study whether PBM behavior is “impacting the accessibility and affordability of prescription drugs” to “lay the groundwork for legislative action as well as for potential, future enforcement actions.” At the same time, the administration has revoked a Biden administration Executive Order that called for “enforcement of antitrust laws to combat excessive concentration of industry,” an action that has created ambiguity for stakeholders with regards to future direction and priorities.

Patient Impacts

Ongoing scrutiny has focused on how changes to ownership and operational practices could impact patient access, costs, and service consistency. PBM ownership, network design and fulfillment practices may influence where patients obtain medications. Legislative or operational changes could alter these dynamics, affecting access to in-network pharmacies, timely receipt of specialty medications, and consistency of medication management and support services.

Although a federal court has temporarily halted implementation of the AR law, stakeholders have raised questions about the potential for disruption in patient access if pharmacies close, especially in areas that already have limited access. Patients with complex conditions could be especially impacted if PBM-pharmacy divestiture efforts result in fewer specialty or retail pharmacies in some areas.

PBM Impacts

Legislation to limit or preclude PBM ownership of pharmacies could also result in transfers in ownership. Current PBM networks and operations may require adjustments, creating uncertainty for all stakeholders heading into the 2026 coverage year.

• Pharmacy-affiliated PBMs: Integrated primary health companies with PBM, pharmacy and insurer operations are the primary target of these reform efforts and could see revenue and operations impacted should the law take effect. Additionally, some of the bills introduced or passed in other states would prohibit PBM-owned mail-order pharmacies, which could further alter network structures and service delivery.
• Non-affiliated PBMs: These entities would not experience direct impacts from legislation but may face new competitive dynamics.

Pharmacy Impacts

• PBM-affiliated pharmacies: Many retail and mail order pharmacies are owned by PBMs and depending on the law’s implementation, they could be divested or face operational changes and closures.
• Independent pharmacies: While divestiture or closure of PBM-affiliated pharmacies could create new opportunities for independent pharmacies, their ability to capture this business will depend on contracting dynamics, reimbursement rates, and overall capacity to absorb additional volume, especially in certain regions.”
• Specialty pharmacies: PBM-affiliated pharmacies made up two-thirds of specialty drug prescription revenue in 2024; changes to ownership rules could alter specialty dispensing channels and associated patient support services, although it may also provide some opportunities for independent specialty pharmacies if they are able to absorb displaced patients.

Health Plan Impacts

Health plans could face operational and contracting challenges under PBM-pharmacy co-ownership legislation, though the degree of impact will depend on how PBMs and pharmacies adapt. Restrictions on mail-order or closures of retail and specialty pharmacies could affect network adequacy and patient access, while contract renegotiations may lead to shifts in reimbursement dynamics that remain difficult to predict.

Manufacturer Impacts

Manufacturers could face various logistical challenges in adhering to PBM-pharmacy co-ownership restrictions, including potential disruptions to their contracting or formulary strategies. For those that have relied on PBM-pharmacy platforms for outcomes tracking, alternative data sources may be needed to maintain visibility into patient adherence and experiences.

Specialty prescription drugs that treat complex and rare diseases often require specialty transportation, storage, and patient support. Many limited distribution networks currently include PBM-affiliated pharmacies, and restrictions could disrupt some of these models. At the same time, divestiture requirements may create opportunities for manufacturers to expand relationships with independent specialty pharmacies, renegotiate distribution arrangements, or pursue new data partnerships. The long-term implications will depend on how distribution channels evolve and how manufacturers adapt their strategies for access, support, and evidence generation.

Next Steps
Given state and federal interest in PBM oversight and reform, stakeholders should remain vigilant of the downstream effects of legislation like PBM-pharmacy co-ownership prohibitions. Specifically, if the federal injunction on AR Act 624 is lifted, there will be both significant change for drug distribution channels in Arkansas and across the nation as consequences reverberate across national pharmacy and PBM chains, and as similar state-level legislation is possibly considered. Though the drug supply chain is complex, with expertise across various lenses of health plan strategy, Avalere Health is well-positioned to be a valuable thought partner to help your business navigate these changing dynamics and position you favorably in the future. Connect with us to learn more.