Monthly Legislative & Lobbying Activity Report for April 2026
Legislative Activity
Additional PBM Legislation Introduced
In April, lawmakers continued to advance targeted prescription drug and PBM-related legislation, reinforcing sustained bipartisan interest in addressing formulary design, pricing dynamics, and patient access to lower-cost therapies. While no comprehensive PBM reform package emerged, the legislation introduced during the month focused on discrete but meaningful policy levers within Medicare and the commercial market.
- Medicare Formulary Access to Lower-Cost Drugs. 4323, the Ensuring Access to Lower-Cost Medicines for Seniors Act (Introduced April 16, 2026). Introduced by Sen. James Lankford (R-OK), the bill would require Medicare Part D plans to provide more meaningful access to lower-cost generics and biosimilars beginning in 2028. The legislation would constrain PBM formulary practices by requiring plans that cover a reference product to also cover lower-cost alternatives, prohibit utilization management tools that favor higher-cost drugs, and mandate placement of qualifying generics and biosimilars on lower-cost tiers.
- Insulin Pricing and PBM Transparency. 4189, the INSULIN Act (Introduced March 25, 2026). Introduced by Sen. Jeanne Shaheen (D-NH), the bill would establish broad insulin affordability protections, including requiring PBMs to pass through 100 percent of insulin-related rebates and fees to health plans, mandating detailed disclosures and audit rights, and limiting utilization management restrictions on insulin products. The bill would also tie patient cost-sharing to net prices beginning in 2028.
Hearings
- House Education and the Workforce Subcommittee Hearing. On April 22, the House Education and the Workforce Subcommittee on Health, Employment, Labor, and Pensions held a hearing titled “Profits Over Patients: The PBM Business Model Under Scrutiny.” The hearing featured employer, policy, and academic witnesses and focused heavily on PBM compensation practices, broker/consultant conflicts of interest, vertical integration, and utilization management tools such as step therapy.
The tone of the hearing was broadly critical of PBM practices, with notable bipartisan alignment on concerns related to transparency, market concentration, and misaligned incentives. Republicans focused particularly on consultant kickbacks, spread pricing, and vertical integration, while Democrats generally agreed on the need for reform but emphasized that PBM transparency alone will not address underlying drug prices set by manufacturers.
The hearing was constructive. Members repeatedly highlighted issues central to independent pharmacy concerns, including reimbursement pressure, steering, formulary manipulation, and lack of transparency. The discussion reinforced that PBM reform remains a live and bipartisan policy issue, particularly around conflicts of interest, data access, and patient access to appropriate therapies.
Federal Regulatory Activity
- State Attorneys General Support DOL PBM Transparency Rule. On April 15, a bipartisan coalition of 45 state and territorial attorneys general submitted a letter supporting the Department of Labor’s proposed PBM transparency rule. The coalition endorsed stronger disclosure requirements while urging DOL to clarify that the rule would not preempt state PBM laws and to coordinate with state enforcement authorities.
- Continued Pressure to Finalize DOL Rule. According to reports, employers, lawmakers, and patient advocates continue to press DOL to finalize its proposed PBM transparency regulation. The rule would require PBMs to disclose detailed, transaction-level compensation information — including rebates, spread pricing, and fees — and provide employers with audit rights. If finalized, the rule would represent a significant step toward increased transparency in the employer-sponsored market.
Other Policy Activity
- Politico Health Care Summit (April 21, 2026). At the summit, Mark Cuban, co-founder of Cost Plus Drug Company, used his remarks to criticize the market power of vertically integrated insurers and PBMs. Cost Plus was created to offer a more transparent, direct-to-consumer pharmacy model that prices medications based on acquisition cost plus a fixed markup, rather than relying on the traditional PBM rebate and formulary system.
Cuban argued that PBM-insurer consolidation distorts drug pricing, limits competition, and can discourage manufacturers from working with alternative purchasing models like Cost Plus. He urged policymakers to pursue more aggressive structural reforms, including proposals such as the Warren-Hawley Break Up Big Medicine Act, to address consolidation across the healthcare supply chain.
Legislative Outlook
April activity further underscored a familiar dynamic: policy momentum around PBM reform remains strong, but the legislative pathway for additional action this year remains constrained.
Lawmakers continue to introduce targeted reforms, hold oversight hearings, and engage actively on PBM-related issues. At the same time, conversations with congressional offices consistently reflect skepticism that major standalone PBM legislation will advance in the near term absent a clear legislative vehicle. That reality has become more apparent as broader legislative opportunities have narrowed.
In particular, Congressional Republicans continued to advance a second budget reconciliation package during April, but the emerging vehicle is significantly more limited than earlier proposals that contemplated broader healthcare reforms. On April 23, the Senate passed a FY2026 budget resolution focused primarily on immigration enforcement funding, which the House adopted on April 30. The resulting framework is expected to support a targeted reconciliation bill centered on border security, rather than a broader healthcare package.
There has also been some discussion within the Administration — including from CMS Administrator Mehmet Oz — about a potential third reconciliation package later this year that could be more healthcare-focused. However, most observers view that scenario as unlikely given time constraints, competing priorities, and the procedural complexity of advancing multiple reconciliation bills.
Importantly, even if healthcare provisions were included in a future reconciliation package, PBM reform would face significant procedural hurdles under the Byrd Rule. Several PBM provisions were removed from prior reconciliation efforts for failing to meet budgetary requirements, underscoring that reconciliation remains a challenging and uncertain pathway for advancing comprehensive PBM reforms.
Prepared by Steven Irizarry, Managing Partner, and Casey Davison, Partner.