CMS Prepares For New Federal PBM Rules For Self-Insured Employer Health Plans

The Centers for Medicare & Medicaid Services (CMS) has posted a new request for information (RFI) targeting pharmacy benefit managers (PBMs) serving Medicare Part D prescription drug plans. CMS staffers intend to use the data they collect to implement new rules for PBMs serving those plans. This action gives those in the benefits industry a preview of how the new PBM rules for self-insured employer health plans may operate.

The Consolidated Appropriations Act, 2026, which took effect in February 2026, established rules governing PBMs in both self-insured employer plans and Medicare plans. CMS can implement the PBM rules for Medicare on its own. However, the PBM rules for employer plans will be issued by the collective action of the U.S. Department of Health and Human Services, the Internal Revenue Service, and the U.S. Labor Department’s Employee Benefits Security Administration.

PBMs must comply with the new rules for Medicare plans no later than July 1, 2028. These rules require PBMs serving these plans to pass on any rebates or other discounts they receive to patients. PBMs may also receive only flat-dollar service fees, must allow patients to use any pharmacy that accepts the PBMs’ prices, and must require participating PBMs to provide detailed compensation and operations reports.

Similarly, the PBM rules governing self-insured employer plans require PBMs to pass on any rebates they receive to employers. PBMs serving these plans also must submit detailed compensation and operations reports.

The RFI seeks to collect various types of information, including the definition of PBM and its duties. The CMS RFI also asks for information about entities that provide functions through intermediary categories on behalf of a plan sponsor or plan. More specifically, the RFI asks for information on the intermediaries’ ownership, contractual relationships between intermediaries and PBMs, the services performed, the payments received, variations in those payments, and the sources of those payments. The RFI also requests the definition of “affiliate” relative to a PBM and the types of entities that might qualify as affiliates. Potential affiliates include group purchasing organizations, payment facilitators, pharmaceutical relabelers, and data vendors.

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