PUTT Blog | Question of the Month: Why is it so Difficult to Enforce PBM Laws?

A collection of recently published state and federal documents has us scratching our heads and asking, “why is it so difficult to enforce certain PBM reform laws?” 

In the last few weeks we’ve seen:

• incomplete state audits or audits rendered inconclusive because PBMs didn’t turn over files as directed by state law; or audits revealing what appears to be a complacent attitude toward implementing the state’s PBM reform laws  

• laws barring spread pricing, or below-cost reimbursements, or laws requiring payment of a fair dispensing fee obviously broken, seemingly without major repercussion; 

• a PBM using its market dominance, lies and threats to suppress independent pharmacies then failing to produce evidence to support fraud allegations when requested by the federal government; 

• and a high-profile FTC settlement in which Express Scripts, the sole provider for at least one major government pharmacy contract (TRICARE), made a deal that includes no financial penalties or admission of wrongdoing and reads as if its legal counsel wrote the terms and conditions for them. Oral arguments in the FTC’s case against CVS Caremark, OptumRx et al are set to begin next week on March 5.  

We all work extremely hard with our lawmakers to pass meaningful legislation meant to protect our patients, pharmacies and communities from obvious profit-motivated PBM practices. So it can be discouraging to watch what looks like sloppy, C-level effort on the part of PBMs when states attempt to enforce their laws. Why is it so hard to get them to follow the law?

We’d really like to know, so beginning with our own declaration that March is now “PBM Law Enforcement Awareness Month” we’ll be examining aspects of PBM reform laws, regulatory enforcement, and the challenges that arise when states seek to enforce their laws. 

We invite you to join us as we:

• Submit our comments and recommendations to the FTC on the ESI Settlement with the goal of helping to shape future settlement terms and conditions. 

• Encourage EVERYONE EVERYWHERE to please submit your comments and ideas before the March 16, 2026 deadline. Not sure what to say? Check out the PUTT Board’s notes from our own thorough review of the settlement terms for additional ideas.

• Tune into a special PUTTcast episode in mid-March featuring Matt Seiler, NCPA VP and Special Counsel; Miguel Rodriguez, EVP and General Counsel at American Pharmacies; and Mark Boesen, PharmD, J.D. and Principal at Boesen & Snow Law. We’ll be looking at the intricacies of enforcing PBM reform laws with an eye toward the Express Scripts settlement.

• Explore further opportunities, takeaways and lessons learned ahead of the NCPA Fly In on April 15-16 in Washington, DC. Not registered? We strongly encourage you to join us there to raise awareness of the need to break down the seemingly “too big to jail” mentality some PBMs appear to exhibit when it comes to complying with state law.

As always, thank you for fighting for PBM reform, and thank you for supporting PUTT. Here’s to “PBM Law Enforcement Awareness Month” - let’s roar it in like lions!

Yours in advocacy,

Monique Whitney

Executive Director