Could forcing PBMs to sell pharmacies lower drug costs? Lawmakers want a breakup test

Patients Before Monopolies Act returns

Prescription drug prices already feel confusing enough, and lawmakers say the intermediary system may be making it worse. The Patients Before Monopolies Act would bar common ownership of pharmacies with PBMs or health insurers, requiring affected parent companies to divest their pharmacy businesses.

Supporters say that the setup creates conflicts of interest. They argue a company should not help decide drug access and payments while also running pharmacies that compete for those prescriptions.

Patients Before Monopolies targets PBMs

The Patients Before Monopolies Act was reintroduced by Sens. Elizabeth Warren and Josh Hawley, with a House version from Reps. Diana Harshbarger and Jake Auchincloss. That bipartisan lineup shows how PBM reform has moved beyond one party.

The bill focuses on large healthcare companies with both pharmacy benefit management and pharmacy ownership. Backers say the goal is to lower drug costs, protect patients, and help independent pharmacies compete more fairly.

Patients Before Monopolies speeds divestment

The Patients Before Monopolies Act would give affected companies 1 year to sell their pharmacy business. An earlier version allowed 3 years, so the new version moves faster.

That shorter deadline is a big deal. Companies like CVS Health, Cigna, and UnitedHealth Group operate in complex pharmacy, insurance, and PBM networks. Breaking those pieces apart would not be a small paperwork change. It could reshape how millions of prescriptions are priced, filled, and managed.

What PBMs actually do

PBMs sit between drugmakers, insurers, employers, pharmacies, and patients. They help decide which drugs are covered, what pharmacies are in network, and how much pharmacies get paid.

In theory, PBMs use their size to negotiate better prices. Critics say the system has become too hidden and too concentrated. Patients may never see the full path from list price to rebate to pharmacy payment. That lack of clarity is why lawmakers keep pushing for reform.

Why lawmakers see a conflict

The conflict argument is easy to understand. If a company owns a PBM and a pharmacy, it may have reasons to steer prescriptions toward its own pharmacy business.

Independent pharmacies say that this can leave them with lower payments and fewer customers. Large companies disagree, saying their combined platforms can make care smoother and cheaper. The fight is really about control. Lawmakers want to know whether the same company should influence drug access and also profit from where prescriptions are filled.

CVS is in the spotlight

CVS Health is central to the debate because it owns CVS Pharmacy and CVS Caremark, one of the nation’s biggest PBMs. It also owns Aetna, a major health insurer.

That structure is exactly what reformers want to challenge. CVS argues its model delivers value to patients and members through a coordinated platform. Critics say the same model gives one company too much power over prescriptions. The federal bill could force a major rethink if it becomes law.

Tennessee became a warning sign

Tennessee lawmakers passed the Fair Rx Act, which would restrict certain companies from owning a pharmacy while also owning a PBM and a health insurer, sparking a major fight over access and competition.

Supporters called that warning pressure politics. CVS said the law threatens pharmacy access and jobs. Either way, Tennessee shows what could happen if ownership separation becomes real. A legal fight is likely, and other states are watching closely before making their own moves.

Fun fact: CVS has warned that Tennessee’s Fair Rx Act could force it to close 134 pharmacies in the state and could affect about 2,000 jobs.

Independent pharmacies want relief

Small pharmacies say PBM rules can make it hard to stay open. They often complain about low reimbursement rates, fees, and limited negotiating power against giant healthcare companies.

For patients, that matters because independent pharmacies can be important in rural towns, small cities, and neighborhoods with fewer healthcare options. If those pharmacies close, people may have to drive farther or wait longer for medication. Supporters of the bill say breaking up ownership could help level the field.

Fun fact: The FTC said PBM practices may squeeze independent pharmacies and affect patient access to care.

Opponents warn of more confusion

PBM industry groups say the bill could further fragment the healthcare system. They argue patients already dislike how complicated the system is, and breaking companies apart could add more steps.

That is the main counterargument. Big companies say their connected systems can manage benefits, pharmacy access, and costs in one place. Critics reply that “one place” can also mean less competition. The debate is not whether the system is complicated. The question is whether consolidation helps or harms patients.

Federal agencies would enforce it

The bill gives enforcement roles to the Federal Trade Commission, the Justice Department, the Department of Health and Human Services, and state attorneys general. That means violations could face pressure from several directions.

That enforcement design matters because PBM ownership is not a small local issue. It touches national drug chains, insurers, employers, Medicare plans, and millions of covered patients. Lawmakers want regulators to have enough authority to force real separation if companies refuse to comply.

States are pushing Congress

In 2025, a coalition of 39 state attorneys general urged Congress to act on PBM ownership and pharmacy conflicts. That kind of pressure gives federal lawmakers extra political cover.

States have been dealing with pharmacy closures, pricing complaints, and access concerns for years. Some want national rules because PBMs operate across state lines. Others are passing their own laws first. Either way, the message is clear: drug pricing intermediaries are now under serious bipartisan scrutiny.

Medicare already saw reform

Congress has already moved on to some PBM practices. A 2026 federal funding law included Medicare Part D PBM reforms that ‘delink’ PBM compensation from drug prices and rebate arrangements, with key requirements slated to apply beginning in the 2028 plan year.

That reform does not break up pharmacy companies. But it shows lawmakers are willing to change how PBMs make money. The new Warren-Hawley bill goes further by targeting ownership itself, not only fees or transparency.

For another pharmacy policy fight that could affect drug costs, find out more about how a new tariff threat targets patented drugs and puts pharma on a deadline.

The cost question remains

The big promise is lower drug costs, but the path to that goal is not guaranteed. Breaking up ownership could reduce conflicts and help competition, but it could also disrupt pharmacy networks and business systems.

That is why the fight will be intense. Patients want lower prices. Independent pharmacies want fair payments. Big companies want to protect their model. Lawmakers want proof that the system is not rigged. The bill may not be the final answer, but it shows the pressure for change is growing fast.

For another drug pricing fight that could affect patients and pharmacies, find out more about how Tennessee’s new bill targets pharmacy benefit managers and raises hopes for prescription price relief.

Do you think breaking up big pharmacy companies could lead to fairer drug prices for patients? Share your thoughts and drop a comment.

This slideshow was made with AI assistance and human editing.

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