CMS Seeks Information on Pharmacy Benefit Manager Compensation and Data Reporting

What this means for your practice

This CMS RFI, while directly targeting Pharmacy Benefit Managers, has significant indirect implications for telehealth brands, medspas, dental practices, and chiropractic offices, particularly those involved in prescribing medications or managing patient drug benefits under Medicare Part D. Changes to PBM remuneration and increased data reporting could lead to greater transparency in drug pricing and potentially impact medication costs, formularies, and pharmacy networks. Healthcare providers should monitor these developments as they could influence patient access to prescribed drugs, reimbursement for drug-related services, and the overall economics of pharmaceutical care. Practices operating in states with Corporate Practice of Medicine (CPOM) regulations, or those considering or currently engaging in dispensing activities, should pay close attention to the evolving landscape of drug benefit management.

Washington D.C. — The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), has published a Request for Information (RFI) in the Federal Register, seeking technical input on the business practices of Pharmacy Benefit Managers (PBMs) and their affiliates. This RFI, identified by file code CMS-4218-NC and RIN 0938-AW09, is crucial for informing the implementation of recent legislative mandates that will impact the Medicare Part D program.

Background and Purpose

The RFI's primary objective is to gather information to inform two specific legislative requirements mandated by Section 6224 of the Consolidated Appropriations Act, 2026 (CAA, 2026). These requirements are slated to take effect beginning in Calendar Year (CY) 2028. The two key areas of focus are:

1. Restrictions on PBM Remuneration: New limitations on the compensation PBMs and their affiliates may receive for services related to the utilization of covered Part D drugs. 2. Data Reporting Requirements: Enhanced data collection obligations for PBMs regarding their operations and financial arrangements.

CMS emphasizes that this request for technical input is narrowly focused on these two aspects of Section 6224. Other provisions of the CAA, 2026, including compliance and enforcement mechanisms, Part D pharmacy contracting standards, and affiliate pharmacy/pharmacy incentive payment reporting requirements (from Section 6223), are being implemented separately and are not the focus of this specific RFI.

Defining a Pharmacy Benefit Manager

The Social Security Act, specifically Section 1860D-12(h)(7)(C), provides a broad definition of a "pharmacy benefit manager." It encompasses any person or entity that, directly or through an intermediary, acts as a price negotiator or group purchaser on behalf of a prescription drug plan (PDP) or PDP sponsor, or manages the prescription drug benefits provided by such a plan or sponsor. This definition explicitly includes entities performing functions such as:

• Claims processing
• Utilization review
• Prior authorization
• Appeals adjudication
• Pharmacy network contracting
• Cost control

Notably, the definition applies regardless of whether the entity explicitly calls itself a pharmacy benefit manager, and includes the provision of "related services."

Call for Public Comments

CMS is actively soliciting information from interested parties to inform future rulemaking based on Section 6224 of the CAA, 2026. Commenters are encouraged to clearly identify which sections of the RFI their responses address and to provide specific examples, data, or documentation where possible. While all relevant input is invited, CMS encourages a focus on the remuneration restrictions and data reporting requirements.

To ensure consideration, comments must be received by 5 p.m. on July 20, 2026. Submissions can be made electronically through regulations.gov, or via regular or express mail to the addresses provided by CMS.

All comments received before the close of the comment period will be publicly available for inspection on regulations.gov, including any personally identifiable or confidential business information submitted. CMS will not post comments containing threats or suggesting harm to individuals or institutions.

Importance for Healthcare Practices

While PBMs primarily interact with pharmacies and drug plans, their practices have a ripple effect throughout the healthcare ecosystem. For telehealth brands, medspas, dental practices, and chiropractic offices, particularly those that prescribe medications or engage in any form of drug management:

• Drug Costs and Access: Future regulations resulting from this RFI could influence the cost of medications and patient access to specific drugs, directly impacting treatment plans and patient adherence.
• Transparency: Increased transparency in PBM compensation and data reporting could lead to a more equitable and predictable pharmaceutical supply chain, potentially affecting direct dispensing models or referrals.
• Compliance Monitoring: Healthcare providers should stay informed about these federal developments, as they set the stage for how drug benefits will be administered and reimbursed, which can impact practice economics and patient care strategies. Understanding PBM practices can also be vital for navigating insurance coverage discussions with patients and ensuring access to necessary therapies.

Key Facts

| Detail | Value | |---|---| | Agency | Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS) | | Action | Request for Information (RFI) | | Purpose | Solicits technical input to inform implementation of recent legislation regarding Pharmacy Benefit Manager (PBM) practices. | | Legislative Basis | Section 6224 of the Consolidated Appropriations Act, 2026 (CAA, 2026) | | Key Requirements Effective Date | Calendar Year 2028 for PBM remuneration restrictions and data reporting | | Comment Deadline | July 20, 2026, by 5 p.m. | | File Code | CMS-4218-NC | | RIN | 0938-AW09 |

Frequently Asked Questions

What is the purpose of this CMS RFI?

The RFI solicits technical input on PBM services and business practices to inform the implementation of recent legislation, specifically regarding PBM remuneration restrictions and data reporting requirements for Part D drugs.

When will the legislative requirements informed by this RFI become effective?

The restrictions on PBM remuneration and data reporting requirements are effective beginning Calendar Year 2028.

What specific legislative requirements is CMS seeking information on?

CMS is gathering information on restrictions on the remuneration PBMs and their affiliates may receive for Part D drug services, and on data reporting requirements, both stemming from Section 6224 of the Consolidated Appropriations Act, 2026.

How does the Act define a 'Pharmacy Benefit Manager'?

Section 1860D-12(h)(7)(C) of the Act broadly defines a PBM as any person or entity that acts as a price negotiator or group purchaser for a prescription drug plan, or manages its prescription drug benefits, including functions like claims processing, prior authorization, and pharmacy network contracting.

How can interested parties submit comments?

Comments can be submitted electronically via regulations.gov, by regular mail, or by express/overnight mail, and must be received by July 20, 2026.

Source: CMS — Proposed Rule: Request for Information (RFI): Pharmacy Benefit Manager Compensation and Data Collection · 2026-06-18