Impacted: Health plan clietns (Medicare and Medicaid)

What you need to know

On May 22, 2025, the United States House of Representatives passed H.R. 1, a comprehensive spending bill also known as the One Big, Beautiful Bill. This broad bill would reduce Medicaid and Health Insurance Marketplace (or exchange) coverage and contains Medicare delinking provisions that would prohibit pharmacy benefit managers (PBMs) and their affiliates from tying their compensation to Medicare Part D drug prices beginning with the 2028 plan year. In addition, the bill bans spread pricing in Medicaid by increasing transparency and oversight of Medicaid pharmacy reimbursement.  

The bill must still pass the Senate and could undergo changes as part of the deliberations later this summer.

Key provisions

• Delinking of PBM compensation from drug prices: The bill prohibits PBMs and their affiliates from earning revenue based on the list price of a drug, rebates and utilization metrics. Only flat, fair market value (FMV) based service fees directly tied to bona fide services will be permitted.  

• Increased transparency requirements: PBMs would be required to disclose the rebates and fees they negotiate with drug manufacturers, benefit design features, ownership interests in pharmacies and the volume and value of prescriptions filled at affiliated pharmacies. 

• Increased audit rights: Medicare Part D plan sponsors would have broad authority to audit PBMs, including their affiliate pharmacies.  

Prime's position

Prime Therapeutics (Prime) is well-positioned to minimize impact to our clients should H.R. 1 pass the Senate and be signed by the President into law. Since early 2023, Congress has held 23 hearings on PBMs. We believe that advancing targeted Medicare and Medicaid reforms presents an opportunity to share Prime’s value story and potentially preempt broader legislative proposals.  

What sets us apart from other PBMs: 

• Prime’s channel-agnostic, omnichannel pharmacy model is designed to deliver flexibility, affordability, and improved outcomes by allowing members to access medications through the channel that best fits their needs.  

• We do not steer patients to any one pharmacy or location. Note: Accredo is not an affiliate of Prime, but a contracted specialty pharmacy within our network. 

Next steps

The U.S. Senate will conduct deliberations on H.R. 1, with a vote in the near future. Senate Majority Leader John Thune (R-SD) hopes to get the bill to the President by July 4, 2025.  Any changes proposed by the Senate will also need to be approved by the House. Prime is actively assessing H. R. 1 and will closely monitor the bill’s progress, providing timely updates to clients as additional details emerge regarding potential impacts.  We are also communicating with Senators and their staff as this bill progresses.  

Questions

Please reach out to your Prime client account team representative.