WHAT HAPPENED
At the AJMC AXS26 conference in Las Vegas this week, policy experts flagged a fundamental tension that few market access teams have fully modeled: the CAA 2026 PBM reforms were designed for a rebate-driven pricing environment, but MFN pricing, IRA Maximum Fair Prices, and manufacturer list-price cuts are rapidly dismantling that environment. As one panelist noted, the delink rules require PBM compensation to be flat-dollar fees disconnected from drug prices—but emerging pricing mechanisms like MFN and state affordability board upper payment limits are deeply reliant on rebate-type arrangements. The practical implication: another round of legislative refinement is likely necessary once the market absorbs the current changes. Separately, the Pharmaceutical Commerce midterms analysis documented that FTC settlements with Express Scripts, CVS Caremark, and Optum Rx apply only to standard product offerings—employers who prefer legacy rebate arrangements can opt out, creating a bifurcated market that could blunt the reforms' impact.
ALSO THIS WEEK
PBM lobbyists push back hard on DOL transparency rule—500+ comment letters reveal industry fault lines
STAT News reported that PBMs and health insurers mounted stiff opposition to the DOL's proposed rule requiring per-drug remuneration disclosure for self-insured employer plans. A review of over 500 comment letters revealed predictable resistance from PBMs, enthusiasm from Mark Cuban's Cost Plus Drugs and employer advocates, and a contradictory stance from pharma manufacturers who cheered PBM scrutiny while pushing back on their own pricing data disclosure. The comment period closed April 17. If the DOL finalizes alongside the CAA 2026 commercial provisions and reconciliation spread pricing language, PBMs face transparency mandates across every market segment simultaneously.
AHA seeks en banc review of 4th Circuit's West Virginia 340B ruling—argues circuit split demands full court rehearing
The AHA filed an amicus brief on April 17 requesting en banc review of the 4th Circuit's 2-1 panel decision that blocked West Virginia's 340B contract pharmacy law as likely preempted. AHA argues the panel ruling conflicts with the 4th Circuit's own precedent and diverges from the 5th and 8th Circuits, which upheld similar laws. AHA was joined by the West Virginia Hospital Association, 340B Health, and ASHP. If the full 4th Circuit agrees to rehear the case, it could narrow or eliminate the circuit split—reducing the immediate path to Supreme Court certiorari but potentially producing a more durable appellate precedent.
MFN codification push stalls in Congress as midterm politics complicate bipartisan support
AJMC's conference coverage noted that administration efforts to codify MFN pricing agreements through reconciliation face significant headwinds: Democrats are reluctant to hand Republicans a legislative victory heading into midterms, while some Republicans remain skeptical about the scope and enforcement mechanics. The administration has drafted legislative text and invited select manufacturers to discuss terms, but bipartisan hesitation means codification likely stalls before November. The practical implication for manufacturers: MFN agreements remain executive-authority arrangements that could be unwound by a future administration, making long-term pricing commitments around MFN inherently uncertain.
FTC settlement loophole: employer opt-outs could create a two-speed PBM reform market
Pharmaceutical Commerce's analysis flagged a critical structural limitation in the FTC's PBM settlements: the terms requiring delinked compensation and an end to spread pricing apply only to standard product offerings. Employers who prefer legacy rebate-based arrangements retain the ability to opt out. The FTC required Express Scripts to invest $10 million in marketing its standard offering to plan sponsors, but whether employer uptake will be meaningful remains unclear. For market access teams, this means the commercial PBM landscape is fragmenting—some employer plans will operate under reformed rules while others continue under legacy arrangements, complicating contracting strategy and formulary positioning across employer segments.
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