Which states regulate PBMs most heavily?

Arkansas ran the most aggressive PBM legislative slate in the country in its 2025 session, enacting a dozen-plus interlocking laws. HB 1150 (Act 624) bars PBMs from directly or indirectly holding retail pharmacy permits -- a first-in-nation forced-divestiture ban on PBM-owned pharmacies, effective Jan. 1, 2026. SB 104 (Act 514) and SB 544 (Act 775) rewrote the Arkansas PBM Licensure Act to ban ghost/carve-out networks and patient steering, with penalties up to $100,000 per violation; SB 103 (Act 425) created the Pharmacy Nondiscrimination Act (any-willing-pharmacy mandate, same $100,000/violation exposure); SB 475 (Act 773) built a new licensure regime for pharmacy services administrative organizations; HB 1602 (Act 633) added PBM reporting mandates and a $20,000 annual license fee; SB 583 (Act 990) added a private right of action with punitive damages for MAC-list violations; and HB 1703 (Act 570) mandated 110%-of-acquisition-cost reimbursement on successful appeal. Only two related bills failed: HB 1442 (pharmacy contracting/conflict-of-interest restrictions) and SB 589 (340B transparency) both died in Senate committee at sine die.

Louisiana has enacted a run of comprehensive PBM reform laws across the 2025 and 2026 sessions: HB 264 (2025, Act 474, gov. signed 6/20/2025; companion SB 194 died in committee after its 4/14/2025 referral with no further action) banned spread pricing and rebate retention, restricted PBM revenue to management fees, mandated reimbursement of local pharmacies at or above acquisition cost, required transparency reports and an appeals process, and created an insurance-commissioner enforcement fund; HB 1236 (2026, substitute for HB 866, effective 6/12/2026) and SB 387 (2026, Act 914, eff. per its own terms, 1/1/27) layered on a standardized NADAC/WAC-plus-dispensing-fee reimbursement formula, formulary and compensation restrictions, and mandatory annual audits. Two more comprehensive bills remain pending as of mid-2026: HB 938 (NADAC-plus-fee reimbursement, PBM revenue limited to flat fees/bonuses, reverse-auction procurement for state plans; recommitted to the House Finance Committee 5/14/2026) and SB 369 (Medicare-indexed reimbursement floor for the Office of Group Benefits; returned to the calendar 4/8/2026). Further bills in the pipeline - HB 919 and SB 337 (fiduciary duty and transparency), HB 1217 (whistleblower protections, civil penalties, Pharmacy Benefit Enforcement Fund), SB 372 (commissioner examination of vertically-integrated PBM affiliates), SB 377 and SB 381 (revenue/formulary restrictions), and SB 401 (Prescription Drug Affordability Board) - signal continued expansion of an already aggressive regulatory regime.

California enacted sweeping PBM reform via SB 41 (2025, Chapter 605, Statutes of 2025, chaptered Oct. 11, 2025), which bans PBM spread pricing outright, caps enrollee cost-sharing at the actual/disclosed net price paid by the plan or insurer, mandates full passthrough pricing with 100% of manufacturer rebates directed to the payer, protects nonaffiliated pharmacies from discriminatory treatment (while still allowing narrower networks and nonexclusive incentives), and gives the Attorney General civil-penalty and injunctive enforcement authority -- exempting only collectively bargained Taft-Hartley self-insured plans. A companion transparency bill, AB 1773, which would have required a public PBM-licensing website, stalled after its author canceled the committee hearing. This follows earlier California PBM/drug-pricing activity, including SB 786 (2023, Chapter 414) on prescription drug pricing generally, cementing California among the most heavily regulated PBM markets in the country.

Indiana enacted two major PBM laws in 2025 alone: SB 3 (Act, Public Law 69, signed 4/16/2025, effective 2025) imposes an explicit fiduciary duty on pharmacy benefit managers and third-party administrators acting for plan sponsors, requiring loyalty, care, full fee disclosure and conflict-of-interest avoidance; SB 140 (Public Law 189, signed 5/6/2025, applies to health plans issued after 12/31/2025) is a comprehensive PBM reform creating network-adequacy standards, reimbursement and anti-retaliation/anti-discrimination protections for pharmacies, a complaint process, and direct Insurance Commissioner oversight. HB 1604 (Public Law 237, 2025) layered on PBM licensing and cost-sharing/copay-credit mandates. A further conflict-of-interest and downcoding bill, SB 173 (2026), is still advancing (reassigned to Appropriations 1/15/2026). Companion/parallel bills HB 1606, HB 1252, SB 136 (NADAC disclosure/rebate notice), SB 435 and SB 133 (copay accumulator bans), and HB 1571 (PBM fair-reimbursement provisions) all stalled after first reading and did not advance, but the two enacted laws alone put Indiana among the most PBM-restrictive states reviewed, with an active regulator, a codified fiduciary standard, and binding reimbursement/network mandates already in force.

Kansas enacted a sweeping PBM overhaul in SB 20 (2025-2026 session, the Kansas Consumer Prescription Protection and Accountability Act), approved by the Governor 4/9/2026: it bars PBM reimbursement below NADAC (or WAC if NADAC is unavailable) plus the greater of a $10.50 dispensing fee or the K.A.R. 30-5-94 fee, requires PBMs to reimburse pharmacies no less than their own affiliates, requires PBMs to charge health plans the same price paid to pharmacies (an effective spread-pricing ban), mandates rebate pass-through, grants the insurance commissioner PBM examination authority, and raises the unlicensed-PBM fine from $5,000 to as much as $100,000 while repealing the old $10,000/$50,000 aggregate penalty caps. A companion/expansion bill, SB 360, would have added pharmacy-audit standards and further reporting but died in House committee 4/27/2026. Related bills that also died in committee in 2026 include SB 212 (prescription drug affordability board/upper payment limits), HB 2551 (PBM services administrative organization act), SB 423 (cost-sharing counted toward deductibles), and SB 284 (340B anti-interference act). With SB 20 now law, Kansas has one of the most restrictive PBM regimes reviewed: a hard reimbursement floor, an anti-spread-pricing mandate, and steep new penalties.

Rhode Island enacted three separate PBM law packages this cycle, making it one of the heaviest regulators reviewed: SB 3059/HB 8582 (Pharmacy Freedom of Choice -- Fair Competition and Practices, imposing new duties, transparency, and accountability requirements on PBMs) and SB 3060/HB 8579 (the Pharmacy Benefit Managers Act, requiring a certificate of authority from the health insurance commissioner and empowering the commissioner to oversee and penalize PBMs) were both signed by the Governor June 22, 2026; SB 114/HB 5634 (Defending Affordable Prescription Drug Costs Act, 340B nondiscrimination) was signed June 27, 2025. A further wave remains pending, including SB 165 (spread-pricing ban), SB 222/HB 5254 (NADAC-plus-fee reimbursement floor), SB 2466/HB 7189 (fair-reimbursement and anti-discrimination rules), and HB 7692/SB 117 (Medicaid MCO/PBM transparency), all held for further study -- meaning even more restriction is plausible in the next session.

Tennessee has been one of the most active PBM-regulation states in 2025-2026. The FAIR Rx Act (SB 2040/HB 1959) bans PBMs and health insurers from owning, operating, or controlling pharmacies starting July 1, 2028; HB 1959 became Pub. Ch. 1111, effective 5/22/2026. A companion prompt-pay measure (HB 1244/SB 881) subjected PBMs to existing insurance prompt-payment penalty statutes; HB 1244 became Pub. Ch. 446 (2025), with SB 881 effective 5/9/2025. Beyond enactments, a wave of 2026 bills sought a NADAC/WAC-based minimum-reimbursement floor and dispensing-fee mandate (HB 2332/SB 2576), prescriber-authority/anti-interference protections with civil penalties (HB 2333/SB 2574), a ban on state contracts with disciplined PBMs (HB 2331/SB 2577), an annual PBM-violation public reporting mandate (HB 1955/SB 1796), and a new Tennessee Commission of Insurance Review with ownership-overlap and AI-review restrictions (HB 2619/SB 2155, the latter failed in Senate Commerce and Labor). Most died in subcommittee this session, but the sheer volume signals sustained, escalating legislative pressure toward heavier PBM regulation.

North Dakota enacted a full PBM regulatory overhaul this session: HB 1584 (2025, signed by the Governor Apr. 28, 2025, filed with the Secretary of State the same day, carrying an emergency clause) rewrites Century Code ch. 26.1-27.1, adding PBM licensure, fee limits, prohibitions on certain contracting practices, mandatory pass-through of financial benefits, and a dedicated PBM enforcement fund with civil penalties, while repealing older narrower drug-cost provisions. Its companion on the licensing side, HB 1087 (signed Mar. 14, 2025), tightens licensing standards for PBM and insurance-administrator entities. No dedicated fiduciary-duty clause was added, but the enforcement fund and penalty structure give the new law real teeth.

Colorado enacted two substantive PBM bills in its 2025 session: HB 25-1094 (Pharmacy Benefit Manager Practices, signed by the Governor May 30, 2025) bars PBMs from earning income tied to drug prices, mandates fair reimbursement methods and formulary-design transparency; and HB 25-1222 (Preserving Access to Rural Independent Pharmacies, signed May 27, 2025) sets minimum reimbursement rates and dispensing fees plus fair audit/appeal procedures specifically for rural independent pharmacies. A separate line of bills protecting self-insured employers' 'optimized sourcing' programs from PBM interference -- HB 1012 (2025) and its refile HB 1056 (2026) -- both died, postponed indefinitely in House Health & Human Services. No PBM licensure regime, spread-pricing ban, or fiduciary-duty statute has been enacted.

North Carolina enacted a genuinely comprehensive PBM reform this session: SB 479, the SCRIPT Act (2025, Ch. SL 2025-69, signed by the Governor July 9, 2025), mandates pharmacy-choice protections, requires PSAO licensure and disclosure, bans below-cost pharmacy reimbursement, strengthens pharmacy audit protections, and adds transparency/reporting on rebates and PBM-affiliate dealings, phasing in through 2027. Its House companion, HB 163 (Pharmacy Benefits Manager Provisions, spread-pricing ban and revenue-to-management-fee restriction), remains alive in Senate Rules. A further wave of 2026 bills -- HB 1175 (Affordability in Healthcare Act), SB 976/SB 987/HB 434/SB 316 (Lower Healthcare Costs), SB 839 (Price Transparency Act), and SB 855 (Community-Based Pharmacy Protections) -- remain in committee, meaning further tightening is still possible before session's end.

Iowa enacted a comprehensive PBM reform law in 2025: SSB 1074/SF 383 (companion HF 852 was substituted into it and withdrawn 5/12/2025) passed both chambers (Senate 36-14, House 75-15) and was signed by the Governor 6/11/2025 as Acts Chapter 151. It mandates pass-through pricing, bars discriminatory treatment of pharmacies and pharmacists, imposes cost-sharing transparency, caps PBM reimbursement relative to national drug acquisition cost, and creates pharmacy appeal procedures with reporting to the insurance commissioner. A separate PBM bill, SSB 1207, stalled at the subcommittee stage in March 2025 and did not advance; SSB 1017/SF 315 (PBM reverse auctions for public-employee group insurance) was rereferred to Commerce in May 2025 with no further movement, effectively dying. With one comprehensive reimbursement/transparency law now in force and commissioner oversight established, Iowa sits in the middle of the regulatory-intensity range: meaningfully restricted but without an explicit fiduciary-duty statute.

Contrary to any "no activity" assumption, Nevada enacted real PBM reform in 2025: SB 389 (Chapter 390, signed June 6, 2025) moves Medicaid, CHIP and related state plans to a single state-contracted PBM, bans spread pricing, and creates a Nevada Average Acquisition Cost benchmark for reimbursement; SB 316 (fiduciary-duty, point-of-sale net-pricing, and PBM reporting requirements) passed the Assembly 42-0 and the Senate 18-2 by June 2025, though final gubernatorial action is not reflected in available records; SB 494 (Chapter 514) created the Nevada Health Authority with expanded prescription-drug pricing reporting authority. Broader market-wide bills — SB 209 (steering/spread-pricing ban plus rebate pass-through for all PBMs) and SB 149 (single state PBM model) — both died under the Legislature's Joint Standing Rule 14.3.1 floor deadline. Net effect: Nevada has meaningfully regulated PBMs in its Medicaid/state-plan space this session, even though the broadest commercial-market bills stalled.

Hawaii has already enacted two PBM-adjacent laws and has a comprehensive spread-pricing/NADAC bill moving through conference: SB 1245 (2025, Act 220, eff. upon approval 6/25/2025) set pharmacist insurance-coverage reimbursement standards across health insurers, mutual benefit societies, HMOs and Medicaid plans; HB 1643 (2026, Act 039, eff. 5/26/2026) restricts PBM pharmacy audits and bars PBM exclusion of pharmacies tied to HMO integrated delivery systems. Pending: HB 2225 (2026) would ban spread pricing outright, mandate NADAC-plus-dispensing-fee reimbursement, require rebates reflected in point-of-sale cost sharing, and require pass-through pricing on contracts after July 1, 2027 (in House HLT/CPC as of 1/30/2026, not yet passed); SB 2047 (2026) would reestablish the Insurance Commissioner's statutory PBM/MAC oversight authority (passed Senate, amended twice in House, referred to Finance 3/30/2026); SB 2208 (2026) would ban spread-pricing in the Med-QUEST Medicaid PBM program (stalled in committee). SB 1509 (2025, a PBM study) and SB 2283 (2026, mail-order anti-steering) both died in committee; companion HB 1539 (anti-steering) remains pending.

Contrary to any "no activity" assumption, Montana enacted a substantive PBM reform law this cycle: HB 740 (2025, signed by the Governor May 5, 2025, chapter-numbered, effective for conduct on/after Oct. 1, 2025, sunsets June 30, 2029) bars "effective-rate" reimbursement arrangements functionally equivalent to spread pricing, sets an independent-pharmacy reimbursement floor of NADAC or WAC plus at least a $15 CPI-adjusted dispensing fee, expands prohibited PBM fees, restricts PBM mail-order steering (requiring local fills after a one-day mail-order delay), and imposes MAC/reference-pricing update and audit-recoupment-timing rules. Companion SJ 33 further directs an interim study of the prescription-drug supply chain (due Sept. 15, 2026), signaling continued legislative attention. This is real, enacted, comprehensive-leaning reform, not an inactive state.

West Virginia enacted a substantial PBM reform this cycle: HB 5430 (2026), Chapter 250, Acts, Regular Session 2026, requires PEIA and Medicaid to competitively contract with pharmacy cost-containment vendors, mandates transparency and rebate pass-through, limits charges to pharmacies, prohibits certain PBM ownership structures and reimbursement practices, and requires quarterly PBM reporting plus a dispensing-cost study — but its reach is confined to the state's own PEIA/Medicaid plans, not the broader commercial market. Parallel 2025-2026 bills aimed at commercial PBMs largely died: a fair-reimbursement-at-NADAC-plus-dispensing-fee bill (SB 852, 2025, referred and no further action), a broader reimbursement-limit/ownership-ban bill (SB 907, 2026, referred, no further action), a PEIA-specific PBM oversight and special-investigation-unit bill (HB 5365, 2026, referred), and two sessions of a Prescription Drug Affordability Board bill (HB 2831/2025, HB 5149/2026), none of which passed. A separate bill (HB 5109/2026, HB 3068/2025) sought to narrow the PBM definition itself by removing claims processing from it, cutting the other direction.

Alaska enacted comprehensive PBM oversight through the omnibus insurance bill SB 132 (2025, Chapter 17, SLA 2025, signed 6/24/25), which brought pharmacy benefit managers and third-party administrators under the Division of Insurance's licensing and examination authority, set contract standards between insurers and PBMs, and imposed new reporting obligations. A companion standalone PBM licensure bill, SB 134, and its House twin HB 149 covered similar ground but stalled -- SB 134 was routed to House Rules and HB 149 sat in Health & Social Services without further action, both effectively superseded by SB 132's passage. SB 142, which would extend the same PBM statutes to municipal and state self-insured group health plans (eff. Jan 1, 2026 as drafted), remains pending in Senate Labor & Commerce. No spread-pricing ban, rebate-retention cap, or fiduciary-duty statute has been enacted.

Alabama enacted the Community Pharmacy Relief Act (SB 252, 2025, signed by the Governor April 15, 2025) setting minimum reimbursement rates for independent pharmacies, banning specified unfair PBM practices, requiring rebate-transparency and pass-through toward health benefit plans, and empowering the Commissioner of Insurance to enforce and penalize violations; SB 43 (2025, enacted, eff. Oct 1, 2025) separately bars PBM/insurer gag clauses on cost disclosure. More sweeping PBM licensure bills -- SB 99 and SB 93 (2025, both the 'PBM Licensure, Regulation, and Accountability Act' and a companion reimbursement/audit bill) -- stalled in the Senate Banking and Insurance Committee and never advanced. In 2026, SB 345 is pending in committee to extend reimbursement parity to 'unaffiliated' (non-PBM-owned) pharmacies, while SB 256/HB 372 (both enacted, eff. June 1, 2026) simply staffed up a new PBM Division inside the Department of Insurance, and SJR 45 (2025, enacted) commissioned an outside consultant study on PBM effects rather than imposing new rules.

Delaware built its PBM reform in two enacted steps. HB 212 (2025, signed by the Governor Sept. 3, 2025) rewrote pharmacy overpayment-recovery and audit practices, tightening PBM audit rights. SB 271 (2026, signed Sept. 8, 2026) then went further: it narrows audit practices, expands reimbursement-appeal rights, adds anti-retaliation protections for pharmacies and pharmacists, requires PBMs to use date-specific NADAC or WAC benchmarks, mandates 60 days' notice before contract changes, limits affiliated-pharmacy data transfers, restricts forcing costlier therapeutic substitutions, and shifts PBM disclosures (revenue, rebates, payments) to annual Department of Insurance filings, with a 10-calendar-day window to appeal a PBM's final denial to the Department. Separately, SJR 7 (2025, enacted) and SB 134 (reverse auctions, 2025, enacted) direct the state's own employee-benefits program to use consultants and reverse auctions for drug-cost containment -- procurement tools rather than market-wide mandates. No spread-pricing ban or rebate-passthrough requirement has been enacted.

Utah has steadily tightened PBM rules across sessions. HB 257 (2025), signed 3/27/2025, requires health plans to use pharmaceutical rebates exclusively for enrollee benefit and compels PBMs to offer self-funded plans PBM services without spread pricing — a direct, if scoped, spread-pricing ban. HB 527 (2026), signed 3/19/2026, is a further 'Pharmacy Pricing Amendments' act imposing stricter maximum-allowable-cost (MAC) list rules, a pharmacy appeals process, contract-transparency requirements, penalties for violations, and Insurance Department rulemaking authority. HCR 2 (2025) separately directed the state employee plan (PEHP) to pass rebate value to point-of-sale and optimize its PBM contract. A 2026 task force bill (HB 573) was also filed to study multistate PBM-regulation coalitions. No comprehensive fiduciary-duty statute or blanket spread-pricing ban across all commercial plans exists yet, but Utah's MAC/appeals/transparency regime and self-funded-plan spread-pricing ban meaningfully constrain PBM business practices.

Virginia enacted a significant but Medicaid-scoped PBM reform in 2025: SB 875 and its companion HB 2610 (both Acts of Assembly, Chapters 704 and 701 respectively, 2025) require DMAS to select a single state pharmacy benefits manager for all Medicaid pharmacy benefits, mandate pass-through pricing and transparency, and prohibit spread pricing for that contract. Broader, commercial-market comprehensive PBM bills have repeatedly failed: HB 2773 and SB 1078 (2025, the latter defeated 5-10 in Commerce and Labor) would have imposed an 80%-rebate-passthrough cost-sharing rule, PBM licensure, a fiduciary duty, and a spread-pricing ban across all plans, but both died; HB 1271 (2026) and SB 413/SB 410/HB 631/SB 668 (2026), which would have extended fiduciary duty, pass-through pricing and spread-pricing bans, were left in committee, incorporated into other bills, or continued to next session without passage. So Virginia's enacted PBM regulation currently reaches only its Medicaid pharmacy benefit, not the broader commercial PBM market.

New Jersey's "Patient and Provider Protection Act" (fiduciary duty prioritizing patient interests, formulary tiering favoring generics/biosimilars, flat-fee PBM compensation) has real momentum: Assembly companion A 1502 (2026) passed the Assembly and was referred to Senate Commerce June 18, 2026, while its 2024-25 predecessor A 4953 was reported out of Assembly committee with amendments to Appropriations on Dec. 11, 2025 — neither has reached the Governor. Separately, S 4208/A 5020 (2026, spread-pricing ban with full rebate pass-through and audited PBM financials) and S 3212 ("Pharmacy Fair Reimbursement & Anti-Steering Act," creating a compliance/enforcement unit) were introduced in 2026 and remain in Senate Commerce Committee; S 377 (barring carriers from holding PBM licenses) and S 378 (separate fiduciary-duty bill) are also pending. No PBM-specific bill has been enacted this session, but sustained bipartisan sponsorship and one bill's passage of a full chamber suggest meaningful enactment risk ahead.

Maryland's most sweeping PBM proposal did not become law: HB 1384 (2026), which would have required the state Medicaid program to contract with a single State pharmacy benefits manager bound by fiduciary duties, pass-through pricing, and a spread-pricing ban, was withdrawn by its sponsor 3/20/2026. What did pass is narrower but still substantive: HB 813 (2025, Chapter 730, passed the House 140-0 and Senate 43-0) establishes minimum PBM reimbursement levels tied to Medicaid pharmacy payment; SB 773 (2025, Chapter 692, passed both chambers after a conference committee) sets cost-sharing calculation requirements functioning as a copay-accumulator protection; and SB 357/HB 424 (2025, Chapters 610 and 611, the Lowering Prescription Drug Costs for All Marylanders Now Act) expand the Prescription Drug Affordability Board's authority and stakeholder council. Companion bills SB 303/HB 321 (PBM 'purchaser' definition) and SB 438 (Medicaid PBM administration) both stalled after their 2025 committee hearings with no further action. A 2026 PDAB-related follow-up, SB 837/HB 1440, saw HB 1440 withdrawn by its sponsor in March 2026. Maryland thus sits in the middle: a Medicaid-specific reimbursement floor and an empowered drug-affordability board are in force, but no commercial-market PBM licensure, spread-pricing ban, or fiduciary-duty statute exists.

Oklahoma enacted several PBM bills in 2025 but rejected further restrictions in 2026: SB 773 (modifying PBM definitions and prohibiting certain practices, requiring nonpayment conditions) was vetoed May 10, 2025 but overridden by the Senate 47-0 on May 29, 2025, becoming law; SB 993 (limiting PBM audit findings/reports) and SB 789 (permitting use of certain PBM records without date/source limits) both became law without the Governor's signature (May 22 and May 28, 2025); and HB 2048 (340B nondiscrimination) was filed with the Secretary of State May 29, 2025. Notably, SB 161, which would have imposed a PBM fiduciary duty, died on the Senate floor calendar in Feb. 2025 -- no fiduciary standard exists. In 2026, the legislature passed further PBM restrictions -- SB 1500, SB 2007, and SB 2074 -- but the Governor vetoed all three (May 1-6, 2026) with no override, so those provisions did not become law.

Connecticut's enacted 2025 PBM law is comparatively modest: HB 7192 (Public Act 25-167, signed July 8, 2025) implements bipartisan drug-task-force recommendations -- fair-dealing enforcement against PBMs, enhanced rebate-transparency reporting, a drug-shortage task force, Canadian-importation groundwork, and bulk-purchasing/out-of-network cost-accounting provisions; HB 6436 (signed July 8, 2025) separately adds annual PBM rebate-transparency reporting to the Insurance Department. Far more aggressive bills all died in the Joint Insurance and Real Estate Committee without a vote: SB 1366 and SB 820 would have imposed an explicit fiduciary duty / duty of good faith and fair dealing on PBMs; SB 758, SB 446, and SB 821 would have banned clawbacks and fees and decoupled PBM compensation from drug prices; and SB 1012 would have mandated fee-only PBM compensation. None of that stronger package became law, leaving Connecticut PBMs largely free of fiduciary-duty exposure and compensation restructuring mandates.

Illinois has not enacted a comprehensive PBM reform law in the 2025-2026 sessions, but a dense cluster of comprehensive PBM bills has moved through committee each session without dying outright: HB 1159 and HB 1018 (INS-Pharmacy Benefit Managers, both referred to a dedicated House Pharmacy Benefit Manager Subcommittee and re-referred to Rules through March 2026, still pending) would impose broad PBM licensure, transparency and contracting standards; HB 4761 (Pharmacy Benefit Reimburse, 2026, re-referred to Rules 3/27/2026) would mandate NADAC-plus-dispensing-fee reimbursement and ban spread pricing and steering while protecting 340B pharmacies; SB 1390 (DHFS-MCO-PBM-Contracts, re-referred to Assignments 6/2/2025) and HB 5514 (Medicaid-PBM-Procurement, referred to Rules 2/13/2026) would regulate Medicaid managed-care PBM contracting; HB 4 (Medicaid-Pharmacy Services) remains pending in Rules since March 2025. None of these has reached a floor vote or been signed, so no PBM-specific mandate, fiduciary duty, or licensure regime is yet in force, but the volume and recurrence of comprehensive bills signals sustained legislative appetite for regulation.

Minnesota has repeatedly introduced comprehensive PBM reform without enactment: HF 3931/SF 4062 (2026) would ban spread pricing, restrict PBM compensation to flat management fees, raise licensing fees, and impose fiduciary duties of transparency and fair dealing, but both were merely referred to Health Finance and Policy in March 2026 with no further action. Their 2025 predecessors, HF 2851/SF 3063, carried nearly identical spread-pricing-ban and fiduciary-duty language tied to SEGIP procurement reform and likewise stalled in committee. The consistent reintroduction across both the 2025 and 2026 sessions signals sustained legislative appetite for a spread-pricing ban and PBM fiduciary duty, but as of this session nothing has been signed into law.

Ohio's enacted PBM law this session is licensing-focused rather than a full spread-pricing/fiduciary overhaul: HB 229 (establishing a licensing process and contract requirements for PBMs) was signed by the Governor and takes effect June 30, 2026. Its Senate companion, SB 210 (near-identical licensing/contract text), died in committee in mid-2025. A broader slate of 2025-2026 bills remains pending -- HB 890 (Prescription Relief, Inflation Cost Elimination Act), HB 937 (cost-sharing prohibitions), HB 905 (common-ownership ban for PBM-affiliated entities), HB 665/SB 79 (pricing-algorithm regulation), and HB 192 (Community Pharmacy Protection Act) -- none of which have passed, leaving Ohio's core reimbursement and business-model rules largely untouched beyond the new licensing regime.

Missouri came close but has not enacted comprehensive PBM reform: SB 968/SB 984 (2026, combined into one Senate Committee Substitute) reached the Senate floor with multiple amendments offered and adopted/defeated on April 20, 2026 (NADAC-based reimbursement, MAC transparency, audit and fiduciary-duty provisions) but was not passed to the Governor; companion HB 1975 was reported "Do Pass" by the House Health and Mental Health Committee March 12, 2026 with no recorded floor vote. Their 2025 predecessors — SB 45, SB 512, HB 474, and HB 840 (patient freedom-of-pharmacy-choice, fiduciary duties, MAC appeal rights, copay caps) — likewise advanced through committee or one chamber's calendar without final passage. The repeated near-misses across two sessions signal elevated but not yet realized regulatory risk.

Texas enacted three PBM measures in 2025: SB 1236 (contract transparency, online contract access, fee-schedule disclosure, limits on unilateral adverse changes and recoupment; effective 9/1/25), SB 493 (bars PBMs from gag-clause restrictions on pharmacist cost disclosures and pharmacy-sponsor communications; effective 9/1/25), and HB 3233 (requires PBMs to store/process Texas patient data only within the U.S.; effective 9/1/25). More aggressive bills died: a minimum-reimbursement-at-actual-cost floor (SB 1354/HB 2978, left pending), a ban on carriers steering enrollees to an affiliated PBM (HB 2750, left pending), continuous-coverage-on-PBM-change protection (HB 3542, referred, no further action), a PBM-pharmacy ownership/affiliation ban with reporting (HB 5457, referred, no further action), and a bill applying insurance-law parity to all PBM-administered plans (SB 1122, not placed on intent calendar again). This builds on Texas's existing PBM licensure and contract-fairness framework from 2019-2021 sessions (e.g., HB 1763/2021, effective 9/1/21), so Texas layers incremental transparency/fee mandates onto an already-regulated PBM sector without adopting spread-pricing bans, a reimbursement floor, or a fiduciary duty statute.

Massachusetts has a deep bench of pending PBM bills but none enacted this session: H.1082 ("PBM Compensation Reform Act") would restrict PBM compensation to flat, transparent management fees, ban spread pricing, and mandate annual compliance audits, while companion-style H.1334 would create a new Chapter 175N imposing PBM duties of care, fairness and transparency, banning spread pricing, and giving the insurance commissioner enforcement/penalty authority — its committee reporting deadline was extended to July 31, 2026. At least a dozen more related bills (S.875, H.1167, H.1234, H.1330, H.1296, S.779, H.1324, S.868, S.831, H.4493, H.1325, H.1157, H.1326, S.827, H.4346, H.5618, H.5630) remain in committee. No PBM-specific law has been enacted in the 2025-2026 session, leaving the state's regulatory posture unchanged for now despite heavy pending activity.

Florida's only enacted PBM law in this window is CS/HB 697 (2026, Chapter 2026-4), which revises the definition of pharmacy benefits plans, mandates enhanced administrative appeal rights for pharmacies disputing drug reimbursement rates, prohibits unspecified 'certain PBM practices,' and appropriates ADAP funding with monthly reporting. Its Senate companion, SB 1158, died in Health Policy once HB 697 passed. A long list of more aggressive PBM bills failed across both the 2025 and 2026 sessions: 340B nondiscrimination bills (HB 1527/2025, HB 1281 and SB 1638/2026) all died in committee; insurer/PBM disclosure bills (HB 899 and SB 1342/2025, SB 1166/2026) died; pharmacy-audit bills (HB 1209, SB 1256/2026) died; and Medicaid pharmacy discounted-drug-price bills (HB 657, SB 1064/2025) died. Florida therefore enters this cycle with only a narrow reimbursement-appeal mandate on the books.

Nebraska enacted an incremental strengthening of its existing PBM framework: LB 967 (2026, passed 48-0-1, approved by the Governor April 7, 2026) absorbed LB 1062's amendments to the Pharmacy Benefit Manager Licensure and Regulation Act, adding administrative penalties, a requirement that PBMs notify the Department of Insurance of material business changes, and bringing PBMs under the state's Unfair Insurance Trade Practices Act. This builds on — rather than replaces — Nebraska's pre-existing PBM licensure act; no spread-pricing ban, fiduciary-duty statute, or NADAC reimbursement mandate was enacted or seriously advanced this session (the only other PBM-adjacent bill found, LB 987's "Vision Benefit Plan Act," governs vision benefit managers and was indefinitely postponed).

Washington introduced no new PBM-specific bill (licensure, spread-pricing ban, fiduciary duty, reimbursement floor, or anti-steering measure) in the 2025-2026 session; the state instead relies on its existing 2019 PBM Act (RCW 19.340) licensure/transparency framework, which this session's bills left untouched. The 2025-26 drug-pricing activity that did move was aimed elsewhere: 340B manufacturer-interference protections (SB 5981, enacted, effective 6/11/2026; HB 2145, still in Rules review), vision-benefit-manager regulation that is explicitly non-pharmacy (HB 1770), pharmacist scope-of-practice expansion (HB 1520/SB 5513, SB 5924/HB 2302), biosimilar-access mandates on health plans (HB 1725/SB 5594), and a new tax on prescription-drug warehousing/reselling with pharmacy carve-outs (SB 6228, effective 1/1/2027). None of this reaches PBM conduct, so Washington's PBM-specific regulatory posture is unchanged this cycle.

Maine has not enacted a comprehensive PBM licensure or spread-pricing law in the 2025-2026 session, but it added several narrow, genuinely PBM-specific mandates. SP 821 (An Act Regarding Mail Order Delivery of Prescription Drugs, signed by the Governor 4/13/2026) requires PBMs to let members fill at a network pharmacy at no added cost when a mail-order prescription is late or unusable. SP 135 (An Act to Strengthen the Health Care System in Maine, emergency-signed 4/13/2026) confirms and expands plan sponsors' statutory right to audit PBM/administrator claims and financial data, with breach-notification duties, effective before the 2027 plan year. SP 314 (An Act to Direct the Maine Prescription Drug Affordability Board to Assess Reference-based Pricing, allowed to become law unsigned 1/11/2026) expands the Board's membership and data-collection mandate rather than regulating PBMs directly. A broader hospital/insurer cost bill, HP 1475 (Lower Health Insurance Costs, Reduce Barriers to Health Care and Ensure Fair Prices), remains pending in committee as of February 2026 and is not PBM-specific. With no licensure regime, no fiduciary duty, and no reimbursement-floor statute for PBMs on the books, Maine's PBM business model remains largely unrestricted apart from the mail-order continuity and audit-access rules.

Wisconsin has a comprehensive, heavily bipartisan-cosponsored PBM reform bill actively pending but not yet enacted: AB 173/SB 203 would impose minimum professional dispensing fees, ban certain PBM-charged pharmacy fees, require MAC-list transparency, equalize network reimbursement, protect 340B entities, mandate annual PBM financial disclosure, and — notably — extend a fiduciary duty from PBMs to plan sponsors; as of its last action (February 2026) it remained in committee with cosponsors still being added, not passed. A related health-care-costs omnibus (AB 62/SB 50, including PBM regulation, an insulin $35 cap, and drug importation) has stalled since February 2025. Also pending: manufacturer/PBM price-concession reporting (SB 1149/AB 1170), a ban on PBMs penalizing off-label dispensing (AB 127/SB 137), a plan-sponsor claims-data-ownership mandate against PBMs (SB 703/AB 714), a step-therapy ban for cancer drugs covering PBMs (AB 774), and a stand-alone insulin cost-sharing cap (SB 901/AB 921). None of these have been signed into law; Wisconsin's enacted 2025-26 pharmacy-related acts (2025 Wis. Act 231, drug repository; Act 167, Pharmacy Examining Board membership) are unrelated to PBM regulation.

Kentucky has not enacted comprehensive PBM reform in the 2025-2026 sessions; its one enacted pharmacy-reimbursement measure is narrow. HB 3 (2026, Acts Ch. 99, signed 4/13/2026) adds Kentucky's existing pharmacist-services reimbursement statute (KRS 304.12-237) to the compliance checklist for Medicaid, Medicaid managed care organizations, the state medical assistance program, and KCHIP - extending an existing parity rule to Medicaid MCOs rather than creating new PBM regulation. Its 2025 predecessor of the same title, HB 3 (2025), stalled in House Banking & Insurance after referral and did not pass; SJR 26 (2025, Acts Ch. 23) only directed a legislative report on pharmacist payment parity. A large slate of broader 'prescription drugs' bills - HB 413, SB 12, HB 512, SB 128, HB 453, SB 103, SB 38 (companion to HB 3, reimbursements for pharmacist services), HB 614 (professional dispensing fees, declared an emergency), HB 685 and HB 772 (340B/manufacturer bills), SB 14, HB 389, HB 729, SB 211, SB 307 (step therapy), and SB 340 (all-payer claims database) - were all referred to committee (mostly Banking & Insurance) with no further recorded action, meaning none became law. No spread-pricing ban, no PBM licensure overhaul, and no fiduciary-duty statute exists on the books, leaving Kentucky's PBM business model largely unrestricted outside the narrow Medicaid MCO reimbursement-parity mandate.

Oregon's 2025 session produced an unusually large slate of aggressive PBM bills that almost entirely died in committee upon adjournment: HB 3212 (comprehensive PBM rules covering MAC lists, appeals, and 340B protections), HB 2253 (PBM fiduciary duty to enrollees with a DCBS complaint process), HB 2252 (PBM licensure conditioned on non-insurer ownership), HB 2149 (PSAO licensure), and HB 2057 (340B modifier ban) all stalled. Only two narrower items were enacted: HB 3226 (Chapter 303, 2025 Laws, folding PSAOs into the statutory definition of "pharmacy" so PBM rules reach PSAO contracts) and HB 3409 (Chapter 346, 2025 Laws, eff. Sept. 26, 2025, conditionally allowing 340B claim modifiers while adding some anti-discrimination and data-clearinghouse protections). No fiduciary duty, spread-pricing ban, or ownership-divestiture rule made it into law.

Georgia has enacted PBM reimbursement reform only for its own state employees' plan: HB 196 (2025, effective July 1, 2025) requires index-based (NADAC) pharmacy reimbursement plus a professional dispensing fee for drugs dispensed under the State Health Benefit Plan, with Commissioner of Insurance enforcement. The broader, general-market bills remain stuck: HB 690 and companion SB 60 (2025-2026) would impose an explicit PBM duty of care to insureds, health plans, and providers with a private right of action, but both stalled after early readings; HB 810 would extend the NADAC-plus-dispensing-fee formula to the whole market (excluding state plans and Medicaid) but sits only 'Favorably Reported By Substitute' as of March 2026; HB 100 (80% rebate-passthrough mandate) and HB 101 (rebate-reporting mandate) both stalled/were recommitted in 2025; and SB 91, which would bar the state's Board of Community Health from contracting with PBMs that own retail pharmacies, is likewise still pending in committee. The legislature also created dueling House and Senate PBM study committees (HR 948, SR 927) reporting by Dec. 1, 2026, signaling more action is likely but not yet enacted.