Health Law Diagnosed: PBM Update Spring 2025

Host, Bridgette Keller is joined by Associate, David Gilboa to break down the highlights from our Spring 2025 PBM Policy and Legislative Update. In just five minutes, we cover the most impactful federal and state developments shaping the PBM landscape this season. Tune in to hear about:

• The latest federal transparency proposals and what they could mean for PBMs
• Key takeaways from ongoing FTC litigation
• State-level legislative momentum and emerging trends

Whether you're tracking regulatory shifts or looking for a quick overview of the PBM policy environment, this episode delivers the insights you need — fast.

Read the full Spring 2025 PBM Update here. 

Health Law Diagnosed: PBM Update Spring 2025 — Transcript

Bridgette Keller (BK): Welcome back to Health Law Diagnosed , a Mintz podcast dedicated to health law, health policy, and social issues in the health care industry. I'm Bridgette Keller, your podcast host. Today we're diving into the Spring 2025 PBM Policy and Legislative Update. Joining me is my colleague and fellow policy expert, David Gilboa. David, welcome to the show.

David Gilboa (DG): Thanks, Bridgette, glad to be here, especially with so much happening in the PBM space.

BK: Let's start at the federal level, David. Congress has been busy. What are the standout bills this spring?

DG: Absolutely. We've seen a flurry of bipartisan activity. Key among them is the Pharmacy Benefit Manager Transparency Act of 2025, which aims to ban spread pricing and enforce full disclosure of rebates and fees. It's paired with the Prescription Pricing for the People Act, which directs the FTC to investigate PBM practices like patient steering and formulary manipulation.

BK: And let's not forget the bipartisan Health Care Act, which tried to revive PBM reforms left out of last year's spending bill. It stalled in March, but the momentum didn't stop there.

DG: That's right. The Protecting Pharmacies and Medicaid Act and the Prescription Drug Transparency and Affordability Act both push for pass-through pricing and stricter reporting. And just last month, the House passed a reconciliation bill nicknamed the One Big Beautiful Bill that includes PBM reforms like banning spread pricing in Medicaid and limiting PBM compensation in Medicare Part D to bona fide service fees.

BK: With all this pressure, PBMs are responding. What are we seeing from the big players?

DG: Well, Cigna's Express Scripts and UnitedHealth's Optum Rx are making moves. Express Scripts is now applying negotiated discounts at the pharmacy counter and capping patient costs. Optum Rx is pledging to pass through 100% of rebates by 2028 and has already eased prior authorization requirements for chronic medications.

BK: And then there's the FTC saga. We've got recusals, reinstatements, and even constitutional challenges.

DG: Exactly. The FTC's insulin rebate litigation was paused due to the commissioner's recusal, but it's expected to resume in July. Meanwhile, ESI is challenging the FTC's 2024 PBM report, and there's a broader legal debate over the agency's structure and commissioner removal protections.

BK: Let's zoom in on the states. What's happening on the ground?

DG: There’s a lot happening at the state level. States are not waiting for Washington anymore. Massachusetts, Missouri, Utah, and North Dakota all passed new PBM laws this quarter. These range from licensing requirements to rebate transparency and anti-spread pricing provisions.

BK: And Michigan is pushing for a prescription drug affordability board, while Montana is considering a bill to mandate NADAC-based reimbursement plus a $15 dispensing fee.

DG: And New York's budget proposal also included aggressive transparency measures, though later scaled back. Still, the trend is clear. States are stepping in where they see federal gaps.

BK: Litigation is heating up too. What should our listeners be watching?

DG: On the litigation front, states like Michigan and California are suing PBMs over alleged roles in the opioid epidemic, claiming they prioritized high-rebate opioids in formularies.

BK: PBMs want those cases moved to federal court, citing their work with Tricare and other federal plans. It's a jurisdictional fight we're watching closely.

DG: There's also momentum in insulin pricing. Minnesota settled with Novo to cap insulin at $35, and Massachusetts filed a suit alleging PBMs and manufacturers colluded to inflate insulin prices in violation of the consumer protection laws.

BK: And don't forget, Maryland just expanded the authority of its Prescription Drug Affordability Board to set upper payment limits, though we are expecting legal challenges here as well.

David, what's your big takeaway from this quarter?

DG: Well, the PBM industry is at a crossroads. Between federal reform efforts, state legislation, and mounting litigation, the pressure is on for transparency, accountability, and structural change in the industry.

BK: Well said. For our listeners, whether you're with a health plan, a PBM, an employer group, or another industry stakeholder, now is the time to stay engaged and be proactive. The landscape is shifting fast.

DG: We'll be here to keep you informed every step of the way.

BK: Thank you so much for joining me today, David. And listeners, thank you for joining us for this episode of Health Law Diagnosed. If you have any questions about the Spring 2025 PBM Update, please feel free to reach out to us directly or email us at [email protected]. I'm Bridgette Keller, and this was Health Law Diagnosed. 

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