S. 1339, Pharmacy Benefit Manager Reform Act

By Fiscal Year, Millions of Dollars

2025

2025-2029

2025-2034

Direct Spending (Outlays)

9

42

16

Revenues

0

-150

-229

Increase or Decrease (-) in the Deficit

9

191

245

Spending Subject to Appropriation (Outlays)

3

2

not estimated

Increases net direct spending in any of the four consecutive 10-year periods beginning in 2035?

< $2.5 billion

Statutory pay-as-you-go procedures apply?

Yes

Mandate Effects

Increases on-budget deficits in any of the four consecutive 10-year periods beginning in 2035?

< $5 billion

Contains intergovernmental mandate?

No

Contains private-sector mandate?

Yes, Over Threshold

The bill would

• Impose new rules for contracts between pharmacy benefit managers (PBMs) and sponsors of private health insurance plans
• Require an exception process for patients undergoing a medication step therapy protocol
• Increase transparency of plans’ health insurance claims, networks, and costs for providers and patients
• Impose private-sector mandates by limiting revenue sources for PBMs, requiring additional data disclosure by health plans, and restricting contracting terms

Estimated budgetary effects would mainly stem from

• Reduced federal subsidies for plan sponsors that benefit from PBM information disclosures and lower the cost of their pharmacy benefits
• Higher administrative costs for insurers and PBMs that would result in higher health insurance premiums
• Increased federal subsidies for health insurance plans whose enrollees access higher priced drugs than they would under current law

Areas of significant uncertainty include

• Anticipating responses by private health insurance plan sponsors and their contracted service providers to the bill’s requirements
• Projecting regulatory decisionmaking and enforcement by federal agencies
• Estimating the effects of those decisions on competition and drug prices