> What’s the deal with PBMs?

PBM INTEL BRIEF: The Pharmacy Benefit Manager Fight

Battlefield

What is a PBM? Pharmacy Benefit Managers are the middlemen between drug manufacturers, insurers, and pharmacies — they negotiate drug prices, set formularies, and process claims. Three companies — CVS Caremark (CVS HEALTH Corp), Express Scripts (owned by Cigna) (EXPRESS SCRIPTS INC), and UnitedHealth's OptumRx — control roughly 80% of the U.S. market. Critics argue they extract billions in "spread pricing" and rebates while driving up costs for patients and independent pharmacies. Defenders (led by the industry trade group Pharmaceutical Care Management Association / PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION PCMA) say they lower costs for plan sponsors.

The legislative stack is enormous. This is one of the most legislated issues in Congress right now, with a decade of bills across multiple Congresses and zero major federal reform enacted:

The most active 119th Congress vehicle is A bill to prohibit pharmacy benefit managers and pharmacies from being under common owners, sponsored by Warren, Elizabeth (Sen. Elizabeth Warren, D-MA) with bipartisan cosponsors including Hawley, Josh (Sen. Josh Hawley, R-MO) and Fetterman, John (Sen. John Fetterman, D-PA). The Warren-Hawley pairing is the key cross-party signal — this is one of the few issues where populist left and populist right converge.

Threats

The industry's primary defense mechanism is PCMA. The Pharmaceutical Care Management Association (PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION) is actively lobbying both chambers in Q1 2026 at $50,000/quarter per registrant, explicitly targeting "government mandates into commercial insurance marketplace for pharmacy benefits managers" and monitoring PBM committee hearings. PCMA also engaged the Trump White House directly — their filings name the Office of Public Engagement and Domestic Policy Council as lobbying targets, and they're tracking the "Big Beautiful Bill" reconciliation vehicle for PBM provisions.

CVS Health (CVS HEALTH) is running parallel lobbying at $105,000 + $60,000 in Q1 2026 alone, targeting the EOP, House, and Senate on "pharmaceutical supply chains and patient access" and "Medicare Part D, Medicare Advantage and Medicaid." CVS's PAC (CVS HEALTH PAC) is spreading money bipartisanly: $5,000 each to Clark, Katherine M. (Rep. Katherine Clark, D-MA), Emmer, Tom (Rep. Tom Emmer, R-MN), Jeffries, Hakeem S. (Rep. Hakeem Jeffries, D-NY), Pallone, Frank (Rep. Frank Pallone, D-NJ), Smith, Jason (Rep. Jason Smith, R-MO), and others — covering both party leaderships and key committee members simultaneously.

The 118th Congress graveyard is the biggest structural threat: Pharmacy Benefit Manager Reform Act was the furthest-advanced PBM reform bill in years — it cleared HELP Committee under Sanders — and still died. The pattern of referral → committee → death has repeated across at least 10 bills since 2022.

Opportunities

The Warren-Hawley bipartisan frame is real. A bill to prohibit pharmacy benefit managers and pharmacies from being under common owners (introduced just 9 days ago, May 13, 2026) has a Republican cosponsor in Hawley, Josh (Hawley, R-MO) — the same senator whose state just received PCMA PAC contributions to Burlison, Eric (Rep. Eric Burlison, R-MO). The antitrust framing (prohibiting PBM/pharmacy common ownership) is more durable than price-control framing and has a better shot in a Republican-controlled Senate.

Labor is already in. The International Brotherhood of Electrical Workers filed a Q1 2026 LDA report explicitly naming To amend the Employee Retirement Income Security Act of 1974 to ensure that pharmacy benef (ERISA fiduciary bill) — the only lobbying filing on any active 119th Congress PBM bill. Labor-backed fiduciary framing (PBMs owe a duty to plan beneficiaries) is a vehicle that could attract union-state Democrats and moderate Republicans simultaneously.

State-level momentum creates federal pressure. Oregon (Requires pharmacy benefit managers to act as fiduciaries to enrollees when negotiating dru, Creates additional rules and requirements for pharmacy benefit managers and a policy or ce), California (Pharmacy benefit managers.), and New York (Relates to reducing pharmacy benefit manager costs) are all moving PBM bills in 2025–26. A patchwork of state laws is the industry's nightmare — it historically accelerates federal preemption negotiations, which can be a vehicle for reform.

The "Big Beautiful Bill" reconciliation window. PCMA's own lobbying filings name the Continuing Resolution and reconciliation as vehicles they're watching for PBM provisions. That means reform advocates have the same window — reconciliation can carry PBM transparency or rebate-pass-through provisions with a simple majority.

Surprising Connections

CVS Health's PAC is funding both the reform advocates' allies AND the defenders simultaneously. CVS gave $5,000 to Pallone, Frank (Rep. Frank Pallone, D-NJ) — one of the most vocal PBM reform champions in the House — while simultaneously lobbying against "government mandates" on PBMs. CVS owns Caremark, one of the Big Three PBMs, but also owns retail pharmacies that compete with PBM-favored mail-order — meaning CVS has a split interest and is hedging both sides of the fight.

PCMA PAC is giving to [McConnell, Mitch](@person-43c4598d-da9f-422d-b928-2b444f610675) (Sen. Mitch McConnell) — the Senate's ultimate gatekeeper — while simultaneously lobbying the Trump White House. The industry is covering every chokepoint.

Warren's top donors are not pharma. Warren, Elizabeth's top funding sources in 2026 are dominated by small-dollar grassroots (12,385 gifts with no employer listed), self-employed, and academic/tech donors (Google, MIT/Harvard, UPenn). No pharma or PBM money in her top 15. This insulates her from the standard industry pressure lever — she can't be bought off on this issue, which makes her a credible lead sponsor but also means she has limited leverage over members who are pharma-funded.

The IBEW lobbying on [To amend the Employee Retirement Income Security Act of 1974 to ensure that pharmacy benef](@bill-hr6837-119) is the sleeper story. A major union self-insures its members' drug benefits and pays PBMs directly — making labor a natural constituency for fiduciary reform that nobody is talking about publicly. If AFL-CIO affiliates pile on, the political math changes.

Recommended Next Moves

1. Dig into [A bill to prohibit pharmacy benefit managers and pharmacies from being under common owners](@bill-s4509-119) swing votes — run swing_votes_needed on this bill to find which Republican senators are movable on the antitrust/ownership-separation frame. Hawley's cosponsor signal suggests there are more.

1. Map PCMA's full lobbying network — pull lobbying_filings_for_org on PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION PCMA (PCMA's second canonical handle) to see which lobbying firms they're retaining and which specific bills they're targeting.

1. Pull CVS Health's full lobbying dossier — lobbying_filings_for_org on CVS HEALTH AND SUBSIDIARIES (CVS Health and Subsidiaries) to see if they're explicitly naming any 119th Congress bills.

1. Check who's funding [Hawley, Josh](@member-H001089) (Hawley) — his cosponsor role on A bill to prohibit pharmacy benefit managers and pharmacies from being under common owners is the key bipartisan signal; knowing whether pharma/PBM money is in his donor base tells you how durable that support is.

1. Track the reconciliation vehicle — PCMA named it explicitly. Any advocate pushing PBM reform should be monitoring the "Big Beautiful Bill" markup for PBM transparency or rebate pass-through amendments.

1. State-to-federal pressure map — pull who_matters_for_bill on Requires pharmacy benefit managers to act as fiduciaries to enrollees when negotiating dru and Pharmacy benefit managers. to identify state legislators who could be mobilized to pressure their federal delegations.