NAIC Spring 2026 Meeting Update: Pharmacy Benefit Management (PBM) (D) Working Group
Summary and Takeaways
- The Pharmacy Benefit Management (PBM) Working Group is moving toward a more robust, standardized PBM examination and oversight framework—expanding focus to affiliated entities (like GPOs), pricing/rebate pass-through, network adequacy, utilization review, complaints, and audits—supported by new licensure guidelines and a forthcoming multi‑state SBS PBM complaint module.
- Federal and federal‑style enforcement pressure is intensifying as the 2026 Consolidated Appropriations Act will overhaul PBM compensation, transparency, and rebate practices in commercial and Medicare Part D markets starting 2028–2029, and the FTC’s proposed Express Scripts settlement signals aggressive scrutiny of rebate‑driven formulary and pricing practices, including the role of PBM‑affiliated GPOs.
On March 23, 2026, the NAIC Pharmacy Benefit Management (D) Working Group met in San Diego to advance PBM oversight items, including discussing new federal PBM reforms and an FTC settlement, SBS complaint handling updates, and a revised PBM examination chapter.
On February 5, 2026, regulators and stakeholders provided extensive comments on the draft PBM Examination Standards Chapter during a virtual meeting focusing on definitions, scope, and examination practicality. Consumer advocates urged inclusion of PBM‑affiliated GPOs in exam scope, greater transparency, public reporting of exam results, identification of violators, and fines. Major PBMs and insurers sought precise language, alignment with statutory authority, protection of confidential information, focused data requests, refined utilization review, and workable audit standards. Examination Resources and INS Companies recommended PBM‑specific expertise, standardized PBM data formats, clarifying reliance on prior exams, defining pharmacy types, and adding standards on PBM organizational structures and affiliates. PBM Navitus urged balancing consumer protection with limiting burdensome disclosures, narrowing requests to regulated markets, and addressed concerns on jurisdiction, point‑of‑sale rebates, duplicative disclosures, and redactions. NCPA supported the draft but pressed for enforcement focus, standardized PBM complaint forms, detailed registration of complaints/appeals, and pharmacist qualifications for PBM examiners.
The working group reported on Congress enacting the 2026 Consolidated Appropriations Act with sweeping PBM reforms emphasizing rebate pass-through, transparency, reporting, and oversight, effective primarily 2028–2029. For commercial markets, PBMs must remit 100% of manufacturer remuneration to plans quarterly, disclose all rebates, support plan audits, and avoid contracts impeding reporting; violations may trigger ERISA prohibited transaction findings, according to the meeting. PBMs become ERISA covered service providers with transparent, quantifiable compensation; overlapping DOL proposals may expand disclosure duties. Medicare Part D changes define PBMs broadly to include rebate aggregators, GPOs, and UM entities, require delinked, flat‑fee, FMV‑based compensation, pass-through of rebates, and standardized annual reporting beginning 2028. CMS will strengthen any‑willing‑pharmacy rules, set “reasonable and relevant” contract standards by April 2028 for 2029, establish a complaint process, and track “essential retail pharmacies.
State Based Systems (SBS) PBM complaint module is being designed with multiple states to handle provider and pharmacy complaints, targeting availability by June 2026. SBS is an electronic system built by the NAIC to automate state-based insurance regulation operations. The Working Group adopted PBM Licensure and Regulation Guidelines for Regulators in December 2025, incorporating Michigan DIFS revisions and refining the “health benefit plan” definition as described in the meeting materials.
The last item on the NAIC’s agenda was the revised Draft PBM Examination, which provides examiner guidance across operations, pricing methodologies, contracts, claims, rebates, network adequacy, utilization review, formularies, complaints, and pharmacy audits, with document requests and review criteria.
