Beyond Spread Pricing: A Shift in PBM Oversight

In 2025, the conversation around pharmacy benefit managers (PBMs) entered a new era.

For years, debate centered on “spread pricing”, the difference between what PBMs bill health plans and what they pay pharmacies. But this year, that narrow focus has widened. Regulators and lawmakers are looking deeper into how PBMs’ ownership structures, reimbursement methods, and internal routing decisions shape the true cost of prescription drugs.

New FTC Reports

On January 14, 2025, the Federal Trade Commission (FTC) released its Second Interim Staff Report: Specialty Generic Drugs – A Growing Profit Center for Vertically Integrated Pharmacy Benefit Managers.

The findings were eye-opening. Pharmacies owned or affiliated with the three largest PBMs, CVS Caremark, Express Scripts, and OptumRx generated over $7.3 billion in dispensing revenue above the National Average Drug Acquisition Cost (NADAC) for 51 specialty-generic drugs between 2017 and 2022. Many of these markups reached “hundreds to thousands of percent” above cost, particularly when filled through PBM-owned pharmacies.

The implications go far beyond pricing. The FTC’s analysis suggests that PBMs are leveraging vertical integration—controlling both benefit design and dispensing—to capture higher internal margins. Across nearly all drug categories studied, PBM-affiliated pharmacies were reimbursed at higher rates than independents. Spread pricing remains a factor, but the conversation has shifted toward how integration directs profits and where it affects transparency and competition.

Developments at the State Level

State and federal leaders are responding quickly. In April 2025, Arkansas became the first state to ban PBMs from owning or operating pharmacies, through House Bill 1150, effective January 1, 2026. Just two months later, Iowa business groups filed a federal lawsuit challenging Senate File 383, which expands PBM reporting and limits reimbursement differences.

By July, the push gained national attention when Arkansas Governor Sarah Huckabee Sanders called for wider action, saying PBM and insurer ownership “has reached a breaking point.”

That same month, the PBM Reform Act of 2025 (H.R. 4317) was introduced in Congress to require public disclosure of PBM incentive payments and restrict undisclosed price differentials between plan sponsors and pharmacies.

The American Medical Association (AMA) echoed the momentum, warning that PBMs’ “high degree of vertical integration continues to hinder competition and affordability,” while urging stronger transparency rules.

Greater Industry Impact

For payers, employers, and pharmacies, the takeaway is clear: oversight is no longer just about pricing—it’s about structure, incentives, and accountability. Even though the FTC’s report reviews data through 2022, its release in 2025 has become the catalyst for a year of major reform.

Looking ahead, additional PBM legislation may soon emerge, including measures requiring PBMs to assume fiduciary responsibility, enforce “any willing provider” participation to prevent discriminatory pricing between networks, and require NADAC-based reimbursement to align payment with true acquisition costs. Each represents another step toward a more transparent and equitable system.

Spread pricing may have started the conversation, but in 2025 and beyond, the focus is firmly on ownership, transparency, and accountability to shape the future of how pharmacy benefits are managed.

For more information on pharmacy developments or for more information on Keenan, reach out to your AssuredPartners team.